CDM CATEGORY SERVICE/ITEM DESCRIPTION UNIT OF MEASURE CPT STANDARD CHARGE UBC CASH CHARGE MINIMUM NEGOTIATED CHARGE MAXIMUM NEGOTIATED CHARGE BCBS PPO CONTRACT BCBS HMO UHC PPO UHC HMO AETNA CIGNA HMO CIGNA PPO 51700524 ALLERGY CLINIC ALLERGY PATCH TEST EACH 95044 "$2,586.00 " 924 "$1,810.20 " "$1,293.00 " "$2,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51700474 ALLERGY CLINIC "ALLERGY TESTING, WITH DRUGS " EACH 95018 $100.00 924 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51700466 ALLERGY CLINIC "ALLERGY TESTING, WITH VENOMS " EACH 95017 $74.00 924 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51700003 ALLERGY CLINIC DESENSITIZATION RAPID EA HR EACH 95180 $986.00 517 $690.20 $493.00 $788.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51700458 ALLERGY CLINIC FOR EXP FLOW W/DIL UP TO 2 YRS EACH 94012 $777.00 460 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51700482 ALLERGY CLINIC INGESTION CHALLENGE - 120 MIN EACH 95076 "$1,326.00 " 924 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51700490 ALLERGY CLINIC INGESTION CHALLENGE-ADD 60 MIN EACH 95079 $344.00 924 $240.80 $172.00 $275.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51700185 ALLERGY CLINIC TEST ALLERGY INTRA W/ALLERG EACH 95024 $152.00 924 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51700227 ALLERGY CLINIC TEST ALLERGY PERC W/ALLERGENIC EACH 95004 "$2,586.00 " 924 "$1,810.20 " "$1,293.00 " "$2,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51700284 ALLERGY CLINIC TEST INTRADERM ALLERGEN DELAY EACH 95028 $100.00 924 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51700292 ALLERGY CLINIC TEST INTRADERM ALLERGEN IMMED EACH 95027 $74.00 924 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 37010014 ANESTHESIA ANES/ANALG CS DELIVER ADD-ON EACH 01968 $500.00 370 $350.00 $250.00 $400.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 37010022 ANESTHESIA ANESTH/ANALG CS HYST ADD-ON EACH 01969 $500.00 370 $350.00 $250.00 $400.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 37010006 ANESTHESIA ANESTH/ANALG VAG DELIVERY EACH 01967 "$1,000.00 " 370 $700.00 $500.00 $800.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 37010295 ANESTHESIA INJ FORAMEN EPIDURAL C/T EACH 64479 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010303 ANESTHESIA INJ FORAMEN EPIDURAL CT ADDL EACH 64480 $800.00 510 $560.00 $400.00 $640.00 65% 80% 50% 50% 65% Non Payable Non Payable 37010329 ANESTHESIA INJ FORAMEN EPIDURAL L/ ADDL EACH 64484 $800.00 510 $560.00 $400.00 $640.00 65% 80% 50% 50% 65% Non Payable Non Payable 37010311 ANESTHESIA INJ FORAMEN EPIDURAL L/S EACH 64483 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010030 ANESTHESIA INSERT EMERGENCY AIRWAY EACH 31500 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% $75 Case Rate $75 Case Rate 37010048 ANESTHESIA INSERT NON-TUNNL CV CTH <5 YR EACH 36555 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010238 ANESTHESIA N BLK INJ SCIATIC CONT INF EACH 64446 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010147 ANESTHESIA N BLOCK CONT INFUSE B PLEX EACH 64416 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010154 ANESTHESIA N BLOCK INJ AXILLARY EACH 64417 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010139 ANESTHESIA N BLOCK INJ BRACHIAL PLEXUS EACH 64415 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010253 ANESTHESIA N BLOCK INJ FEM CONT INF EACH 64448 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010246 ANESTHESIA N BLOCK INJ FEM SINGLE EACH 64447 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010196 ANESTHESIA N BLOCK INJ ILIO-ING/HYPOGI EACH 64425 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010188 ANESTHESIA N BLOCK INJ INTERCOST MLT EACH 64421 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010261 ANESTHESIA N BLOCK INJ LUMBAR PLEXUS EACH 64449 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010089 ANESTHESIA N BLOCK INJ OCCIPITAL EACH 64405 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 37010212 ANESTHESIA N BLOCK INJ PARACERVICAL EACH 64435 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010287 ANESTHESIA N BLOCK INJ PLANTAR DIGIT EACH 64455 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 37010204 ANESTHESIA N BLOCK INJ PUDENDAL EACH 64430 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010220 ANESTHESIA N BLOCK INJ SCIATIC SNG EACH 64445 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010162 ANESTHESIA N BLOCK INJ SUPRASCAPULAR EACH 64418 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 37010097 ANESTHESIA N BLOCK INJ VAGUS EACH 64408 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 37010279 ANESTHESIA N BLOCK OTHER PERIPHERAL EACH 64450 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 37000171 ANESTHESIA (FACILITY CHARGE) ANES CONSCIOUS SEDATION - 1ST 30 MINUTES FIRST 30 MINUTES $400.00 370 $280.00 $200.00 $320.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 37000171 ANESTHESIA (FACILITY CHARGE) ANES CONSCIOUS SEDATION - EACH ADDL 15 MINUTES EACH ADDL 15 MINUTES $400.00 370 $280.00 $200.00 $320.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 37000247 ANESTHESIA (FACILITY CHARGE) GENERAL ANESHTHESIA - 1ST 30 MINUTES FIRST 30 MINUTES "$2,400.00 " 370 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 37000247 ANESTHESIA (FACILITY CHARGE) GENERAL ANESHTHESIA - EACH ADDL 15 MINUTES EACH ADDL 15 MINUTES "$2,400.00 " 370 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 37000106 ANESTHESIA (FACILITY CHARGE) LOCAL ANESTHEISA - 1ST 30 MINUTES FIRST 30 MINUTES $200.00 370 $140.00 $100.00 $160.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 37000106 ANESTHESIA (FACILITY CHARGE) LOCAL ANESTHEISA - EACH ADDL 15 MINUTES EACH ADDL 15 MINUTES $200.00 370 $140.00 $100.00 $160.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000005 AUDIOLOGY AUD ACOUSTIC REFLEX TESTING EACH 92568 $100.00 471 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000013 AUDIOLOGY AUD ASSESSMENT REHAB ADD 15 M EACH 92627 $46.00 471 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000021 AUDIOLOGY AUD ASSESSMENT REHAB FIRST HR EACH 92626 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000039 AUDIOLOGY AUD ASSESSMENT TINNITUS EACH 92625 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000054 AUDIOLOGY AUD CALORIC VESTIBULAR EACH 92533 $37.91 920 $26.54 $18.96 $30.33 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 47000070 AUDIOLOGY AUD COCHLEAR IMP <7 YRS FU EACH 92601 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000088 AUDIOLOGY AUD COCHLEAR IMP <7 YRS REPROG EACH 92602 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000096 AUDIOLOGY AUD COCHLEAR IMP 7 OR > YRS PR EACH 92603 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000112 AUDIOLOGY AUD COMP EVAL THRESH/RECOG EACH 92557 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000120 AUDIOLOGY AUD CONDITION PLAY AUDIOMETRY EACH 92582 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000146 AUDIOLOGY AUD EAR PROTECTOR MEASUREMENTS EACH 92596 $100.00 471 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000153 AUDIOLOGY AUD EVAL CENTRAL FUNCT ADD 15 EACH 92621 $47.00 471 $32.90 $23.50 $37.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000161 AUDIOLOGY AUD EVAL CENTRAL FUNCT INIT 60 EACH 92620 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000179 AUDIOLOGY AUD EVAL ELECTROACOUSTIC BI EACH 92595 $26.06 471 $18.24 $13.03 $20.85 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000187 AUDIOLOGY AUD EVAL ELECTROACOUSTIC MONO EACH 92594 $26.06 471 $18.24 $13.03 $20.85 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000211 AUDIOLOGY AUD EVOKED OTOACOUS EMISS COMP EACH 92588 $777.00 471 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000229 AUDIOLOGY AUD EVOKED OTOACOUS EMISS LTD EACH 92587 $777.00 471 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000237 AUDIOLOGY AUD EVOKED POTENTIAL COMP EACH 92652 $777.00 471 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000252 AUDIOLOGY AUD EVOKED POTENTIAL LTD EACH 92651 $777.00 471 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000260 AUDIOLOGY AUD FILTERED SPEECH TEST EACH 92571 $100.00 471 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000278 AUDIOLOGY AUD HEARING AID CHECK BINAURAL EACH 92593 $98.00 471 $68.60 $49.00 $78.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000286 AUDIOLOGY AUD HEARING AID CHECK MONAURAL EACH 92592 $27.50 471 $19.25 $13.75 $22.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000294 AUDIOLOGY AUD HEARING AID EXAM BINAURAL EACH 92591 $113.00 471 $79.10 $56.50 $90.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000302 AUDIOLOGY AUD HEARING AID EXAM MONAURAL EACH 92590 $2.00 471 $1.40 $1.00 $1.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000658 AUDIOLOGY AUD IMMITTANCE TESTING EACH 92570 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000310 AUDIOLOGY AUD LOUDNESS BALANCE TEST EACH 92562 $777.00 471 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000328 AUDIOLOGY AUD NASAL FUNCTION STUDY EACH 92512 $777.00 920 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 47000336 AUDIOLOGY AUD NASOPHARYNGOSCOPY EACH 92511 $490.00 470 $343.00 $245.00 $392.00 65% of Billed Charges 80% of Billed Charges $116/visit $105/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000344 AUDIOLOGY AUD OPTOKINETIC NYSTAG EACH 92534 $37.91 920 $26.54 $18.96 $30.33 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 47000351 AUDIOLOGY AUD OPTOKINETIC NYSTAG W/REC EACH 92544 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000369 AUDIOLOGY AUD OSCILLATING TRACKING W/REC EACH 92545 $777.00 471 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000377 AUDIOLOGY AUD POSITIONAL NYSTAGMUS EACH 92532 $102.00 920 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 47000385 AUDIOLOGY AUD POSITIONAL NYSTAGMUS W/REC EACH 92542 $316.00 920 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 47000393 AUDIOLOGY AUD POSTUROGRAPHY COMPUTERIZED EACH 92548 $316.00 920 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 47000401 AUDIOLOGY AUD PURE TONE AIR & BONE EACH 92553 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000419 AUDIOLOGY AUD PURE TONE AIR ONLY EACH 92552 $316.00 471 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000427 AUDIOLOGY AUD REHAB POST LINGUAL EACH 92633 $164.00 470 $114.80 $82.00 $131.20 65% of Billed Charges 80% of Billed Charges $116/visit $105/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000435 AUDIOLOGY AUD REHAB PRE LINGUAL EACH 92630 $159.00 470 $111.30 $79.50 $127.20 65% of Billed Charges 80% of Billed Charges $116/visit $105/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000443 AUDIOLOGY AUD SCREEN PURE TONE AIR ONLY EACH 92551 $51.00 471 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000450 AUDIOLOGY AUD SELECT PICTURE AUDIOMETRY EACH 92583 $152.00 471 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000468 AUDIOLOGY AUD SENSORINEURAL ACUITY LEVEL EACH 92575 $100.00 471 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000484 AUDIOLOGY AUD SINUSOIDAL ROTATION W/REC EACH 92546 $387.00 920 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 47000492 AUDIOLOGY AUD SPEECH THRESHOLD EACH 92555 $152.00 471 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000500 AUDIOLOGY AUD SPEECH THRESHOLD W/RECOG EACH 92556 $152.00 471 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000518 AUDIOLOGY AUD SPONT NYSTAGMUS EACH 92531 $80.00 920 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 47000534 AUDIOLOGY AUD STAGGERED SPONDAIC WORD EACH 92572 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000542 AUDIOLOGY AUD STENGER TEST PURE TONE EACH 92565 $152.00 471 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000559 AUDIOLOGY AUD STENGER TEST SPEECH EACH 92577 "$1,326.00 " 471 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000567 AUDIOLOGY AUD SYNTHETIC SENTENCE ID TEST EACH 92576 $100.00 471 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000575 AUDIOLOGY AUD TONE DECAY TEST EACH 92563 $100.00 471 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000609 AUDIOLOGY AUD TYMPANOMETRY IMPED TEST EACH 92567 $100.00 471 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000617 AUDIOLOGY AUD VERTICAL ELECTRODE USE EACH 92547 $81.00 471 $56.70 $40.50 $64.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000625 AUDIOLOGY AUD VISUAL REINFORCEMENT AUDIO EACH 92579 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000633 AUDIOLOGY AUD/ENT UNLSTD PROC EACH 92700 $74.00 471 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000641 AUDIOLOGY BASIC VESTIBULAR EVALUATION EACH 92540 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000104 AUDIOLOGY IV INFS THPY FLD INTL 31MN-1H EACH 92604 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000526 AUDIOLOGY SPONTANEOUS NYSTAGMUS TEST EACH 92541 $316.00 471 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 47000708 AUDIOLOGY TYMPANOMETRY & REFLEX THRESH EACH 92550 $387.00 471 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48196356 CARDIAC CATH 18G 71CM 50 DEGREE CURVE EACH $329.00 272 $230.30 $164.50 $263.20 65% 80% 50% 50% 65% 65% 65% 48196364 CARDIAC CATH 18G 71CM 86 DEGREE CURVE EACH $329.00 272 $230.30 $164.50 $263.20 65% 80% 50% 50% 65% 65% 65% 48196372 CARDIAC CATH 18G 89CM 50 DEGREE CURVE EACH $329.00 272 $230.30 $164.50 $263.20 65% 80% 50% 50% 65% 65% 65% 48196380 CARDIAC CATH 18G 89CM 86 DEGREE CURVE EACH $329.00 272 $230.30 $164.50 $263.20 65% 80% 50% 50% 65% 65% 65% 48196398 CARDIAC CATH 18G 98CM 50 DEGREE CURVE EACH $329.00 272 $230.30 $164.50 $263.20 65% 80% 50% 50% 65% 65% 65% 48196406 CARDIAC CATH 18G 98CM 86 DEGREE CURVE EACH $329.00 272 $230.30 $164.50 $263.20 65% 80% 50% 50% 65% 65% 65% 48196349 CARDIAC CATH 19G 56CM 50 DEGREE CURVE EACH $329.00 272 $230.30 $164.50 $263.20 65% 80% 50% 50% 65% 65% 65% 48196513 CARDIAC CATH 8.5FR 101.5CM 55 DEGREE CURVE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196455 CARDIAC CATH 8.5FR 60CM 120 LONG DEGREE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196448 CARDIAC CATH 8.5FR 60CM 120 SHORT DEGREE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196414 CARDIAC CATH 8.5FR 60CM 15 DEGREE CURVE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196463 CARDIAC CATH 8.5FR 60CM 150 DEGREE CURVE AN EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196422 CARDIAC CATH 8.5FR 60CM 30 DEGREE CURVE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196430 CARDIAC CATH 8.5FR 60CM 55 DEGREE CURVE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196505 CARDIAC CATH 8.5FR 79.4CM 120 DEGREE CURVE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196471 CARDIAC CATH 8.5FR 79.4CM 15 DEGREE CURVE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196489 CARDIAC CATH 8.5FR 79.4CM 55 DEGREE CURVE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196497 CARDIAC CATH 8.5FR 79.4CM 90 DEGREE CURVE EACH C1893 $400.00 278 $280.00 $200.00 $320.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193304 CARDIAC CATH ABLATION CATH-107832RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193288 CARDIAC CATH ABLATION CATH-107890S EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195010 CARDIAC CATH ABLATION CATH-116409RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194252 CARDIAC CATH ABLATION CATH-118330S EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194260 CARDIAC CATH ABLATION CATH-118331S EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194278 CARDIAC CATH ABLATION CATH-118332S EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194286 CARDIAC CATH ABLATION CATH-118431S EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194237 CARDIAC CATH ABLATION CATH-118432S EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194245 CARDIAC CATH ABLATION CATH-118435S EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195499 CARDIAC CATH ABLATION CATH-BD7TCDD4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195622 CARDIAC CATH ABLATION CATH-BD7TCDD8L EACH C1733 "$3,853.00 " 278 "$2,697.10 " "$1,926.50 " "$3,082.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195531 CARDIAC CATH ABLATION CATH-BD7TCDF4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195663 CARDIAC CATH ABLATION CATH-BD7TCDF8L EACH C1733 "$3,853.00 " 278 "$2,697.10 " "$1,926.50 " "$3,082.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195507 CARDIAC CATH ABLATION CATH-BD7TCFF4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195630 CARDIAC CATH ABLATION CATH-BD7TCFF8L EACH C1733 "$3,853.00 " 278 "$2,697.10 " "$1,926.50 " "$3,082.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195523 CARDIAC CATH ABLATION CATH-BD7TCFJ4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195655 CARDIAC CATH ABLATION CATH-BD7TCFJ8L EACH C1733 "$3,853.00 " 278 "$2,697.10 " "$1,926.50 " "$3,082.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195515 CARDIAC CATH ABLATION CATH-BD7TCJJ4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195648 CARDIAC CATH ABLATION CATH-BD7TCJJ8L EACH C1733 "$3,853.00 " 278 "$2,697.10 " "$1,926.50 " "$3,082.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195440 CARDIAC CATH ABLATION CATH-BD7TDD4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195481 CARDIAC CATH ABLATION CATH-BD7TDF4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195457 CARDIAC CATH ABLATION CATH-BD7TFF4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195473 CARDIAC CATH ABLATION CATH-BD7TFJ4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195465 CARDIAC CATH ABLATION CATH-BD7TJJ4L EACH C1733 "$2,703.00 " 278 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196083 CARDIAC CATH ABLATION CATH-BDI35BBRT EACH C2630 "$5,063.00 " 278 "$3,544.10 " "$2,531.50 " "$4,050.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196091 CARDIAC CATH ABLATION CATH-BDI35BDRT EACH C2630 "$5,063.00 " 278 "$3,544.10 " "$2,531.50 " "$4,050.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196034 CARDIAC CATH ABLATION CATH-BDI35BFRT EACH C2630 "$5,063.00 " 278 "$3,544.10 " "$2,531.50 " "$4,050.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194088 CARDIAC CATH ABLATION CATH-BDI35DDRT EACH C1732 "$5,063.00 " 278 "$3,544.10 " "$2,531.50 " "$4,050.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196075 CARDIAC CATH ABLATION CATH-BDI35DFRT EACH C2630 "$5,063.00 " 278 "$3,544.10 " "$2,531.50 " "$4,050.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196042 CARDIAC CATH ABLATION CATH-BDI35DJRT EACH C2630 "$5,063.00 " 278 "$3,544.10 " "$2,531.50 " "$4,050.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196026 CARDIAC CATH ABLATION CATH-BDI35FFRT EACH C2630 "$5,063.00 " 278 "$3,544.10 " "$2,531.50 " "$4,050.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196067 CARDIAC CATH ABLATION CATH-BDI35FJRT EACH C2630 "$5,063.00 " 278 "$3,544.10 " "$2,531.50 " "$4,050.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196059 CARDIAC CATH ABLATION CATH-BDI35JJRT EACH C2630 "$5,063.00 " 278 "$3,544.10 " "$2,531.50 " "$4,050.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195978 CARDIAC CATH ABLATION CATH-BDI75TCDDRT EACH C2630 "$4,858.00 " 278 "$3,400.60 " "$2,429.00 " "$3,886.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196018 CARDIAC CATH ABLATION CATH-BDI75TCDFRT EACH C2630 "$4,858.00 " 278 "$3,400.60 " "$2,429.00 " "$3,886.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195986 CARDIAC CATH ABLATION CATH-BDI75TCFFRT EACH C2630 "$4,858.00 " 278 "$3,400.60 " "$2,429.00 " "$3,886.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196000 CARDIAC CATH ABLATION CATH-BDI75TCFJRT EACH C2630 "$4,858.00 " 278 "$3,400.60 " "$2,429.00 " "$3,886.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195994 CARDIAC CATH ABLATION CATH-BDI75TCJJRT EACH C2630 "$4,858.00 " 278 "$3,400.60 " "$2,429.00 " "$3,886.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195671 CARDIAC CATH ABLATION CATH-BN7TCDD4L EACH C1733 "$6,850.00 " 278 "$4,795.00 " "$3,425.00 " "$5,480.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194542 CARDIAC CATH ABLATION CATH-BN7TCDD8L EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194377 CARDIAC CATH ABLATION CATH-BN7TCDF4L EACH C1732 "$6,850.00 " 278 "$4,795.00 " "$3,425.00 " "$5,480.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194575 CARDIAC CATH ABLATION CATH-BN7TCDF8L EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195689 CARDIAC CATH ABLATION CATH-BN7TCFF4L EACH C1733 "$6,850.00 " 278 "$4,795.00 " "$3,425.00 " "$5,480.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194559 CARDIAC CATH ABLATION CATH-BN7TCFF8L EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194369 CARDIAC CATH ABLATION CATH-BN7TCFJ4L EACH C1732 "$6,850.00 " 278 "$4,795.00 " "$3,425.00 " "$5,480.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194567 CARDIAC CATH ABLATION CATH-BN7TCFJ8L EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195697 CARDIAC CATH ABLATION CATH-BN7TCJJ4L EACH C1733 "$6,850.00 " 278 "$4,795.00 " "$3,425.00 " "$5,480.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195705 CARDIAC CATH ABLATION CATH-BN7TCJJ8L EACH C1733 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194724 CARDIAC CATH ABLATION CATH-BNI35BBCT EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194609 CARDIAC CATH ABLATION CATH-BNI35BBH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194732 CARDIAC CATH ABLATION CATH-BNI35BDCT EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194617 CARDIAC CATH ABLATION CATH-BNI35BDH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194740 CARDIAC CATH ABLATION CATH-BNI35BFCT EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194583 CARDIAC CATH ABLATION CATH-BNI35BFH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194674 CARDIAC CATH ABLATION CATH-BNI35DDCT EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194666 CARDIAC CATH ABLATION CATH-BNI35DDH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194716 CARDIAC CATH ABLATION CATH-BNI35DFCT EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194658 CARDIAC CATH ABLATION CATH-BNI35DFH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194757 CARDIAC CATH ABLATION CATH-BNI35DJCT EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194591 CARDIAC CATH ABLATION CATH-BNI35DJH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194682 CARDIAC CATH ABLATION CATH-BNI35FFCT EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194625 CARDIAC CATH ABLATION CATH-BNI35FFH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194708 CARDIAC CATH ABLATION CATH-BNI35FJCT EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194641 CARDIAC CATH ABLATION CATH-BNI35FJH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194690 CARDIAC CATH ABLATION CATH-BNI35JJCT EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194633 CARDIAC CATH ABLATION CATH-BNI35JJH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194765 CARDIAC CATH ABLATION CATH-BNI75TCDDH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194807 CARDIAC CATH ABLATION CATH-BNI75TCDFH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194773 CARDIAC CATH ABLATION CATH-BNI75TCFFH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194799 CARDIAC CATH ABLATION CATH-BNI75TCFJH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194781 CARDIAC CATH ABLATION CATH-BNI75TCJJH EACH C1732 "$8,563.00 " 278 "$5,994.10 " "$4,281.50 " "$6,850.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196240 CARDIAC CATH ABLATION CATH-C5MHDTCMHS EACH "$1,150.00 " 272 $805.00 $575.00 $920.00 65% 80% 50% 50% 65% 65% 65% 48195606 CARDIAC CATH ABLATION CATH-CR7TCS4RT EACH C1733 "$3,720.00 " 278 "$2,604.00 " "$1,860.00 " "$2,976.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195614 CARDIAC CATH ABLATION CATH-CR7TCS4RTU EACH C1733 "$3,720.00 " 278 "$2,604.00 " "$1,860.00 " "$2,976.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196109 CARDIAC CATH ABLATION CATH-CR7TCSIRT EACH C2630 "$6,850.00 " 278 "$4,795.00 " "$3,425.00 " "$5,480.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196281 CARDIAC CATH ABLATION CATH-CREFP6 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 48194450 CARDIAC CATH ABLATION CATH-D131501 EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194468 CARDIAC CATH ABLATION CATH-D131502 EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194476 CARDIAC CATH ABLATION CATH-D131503 EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194484 CARDIAC CATH ABLATION CATH-D131504 EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195937 CARDIAC CATH ABLATION CATH-D131601 EACH C2630 "$4,500.00 " 278 "$3,150.00 " "$2,250.00 " "$3,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195945 CARDIAC CATH ABLATION CATH-D131602 EACH C2630 "$4,500.00 " 278 "$3,150.00 " "$2,250.00 " "$3,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195952 CARDIAC CATH ABLATION CATH-D131603 EACH C2630 "$4,500.00 " 278 "$3,150.00 " "$2,250.00 " "$3,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195960 CARDIAC CATH ABLATION CATH-D131604 EACH C2630 "$4,500.00 " 278 "$3,150.00 " "$2,250.00 " "$3,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196117 CARDIAC CATH ABLATION CATH-D131801 EACH C2630 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196125 CARDIAC CATH ABLATION CATH-D131802 EACH C2630 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196133 CARDIAC CATH ABLATION CATH-D131803 EACH C2630 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196141 CARDIAC CATH ABLATION CATH-D131804 EACH C2630 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194922 CARDIAC CATH ABLATION CATH-D132701 EACH C1732 "$9,995.00 " 278 "$6,996.50 " "$4,997.50 " "$7,996.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194880 CARDIAC CATH ABLATION CATH-D132702 EACH C1732 "$9,995.00 " 278 "$6,996.50 " "$4,997.50 " "$7,996.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194898 CARDIAC CATH ABLATION CATH-D132703 EACH C1732 "$9,995.00 " 278 "$6,996.50 " "$4,997.50 " "$7,996.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194906 CARDIAC CATH ABLATION CATH-D132704 EACH C1732 "$9,995.00 " 278 "$6,996.50 " "$4,997.50 " "$7,996.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194914 CARDIAC CATH ABLATION CATH-D132705 EACH C1732 "$9,995.00 " 278 "$6,996.50 " "$4,997.50 " "$7,996.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194823 CARDIAC CATH ABLATION CATH-D133601 EACH C1732 "$9,420.00 " 278 "$6,594.00 " "$4,710.00 " "$7,536.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194831 CARDIAC CATH ABLATION CATH-D133602 EACH C1732 "$9,420.00 " 278 "$6,594.00 " "$4,710.00 " "$7,536.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194849 CARDIAC CATH ABLATION CATH-D133603 EACH C1732 "$9,420.00 " 278 "$6,594.00 " "$4,710.00 " "$7,536.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194856 CARDIAC CATH ABLATION CATH-D134701 EACH C1732 "$9,665.00 " 278 "$6,765.50 " "$4,832.50 " "$7,732.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194864 CARDIAC CATH ABLATION CATH-D134702 EACH C1732 "$9,665.00 " 278 "$6,765.50 " "$4,832.50 " "$7,732.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194872 CARDIAC CATH ABLATION CATH-D134703 EACH C1732 "$9,665.00 " 278 "$6,765.50 " "$4,832.50 " "$7,732.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194930 CARDIAC CATH ABLATION CATH-D134801 EACH C1732 "$10,213.00 " 278 "$7,149.10 " "$5,106.50 " "$8,170.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194948 CARDIAC CATH ABLATION CATH-D134802 EACH C1732 "$10,213.00 " 278 "$7,149.10 " "$5,106.50 " "$8,170.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194955 CARDIAC CATH ABLATION CATH-D134803 EACH C1732 "$10,213.00 " 278 "$7,149.10 " "$5,106.50 " "$8,170.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194963 CARDIAC CATH ABLATION CATH-D134804 EACH C1732 "$10,213.00 " 278 "$7,149.10 " "$5,106.50 " "$8,170.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194971 CARDIAC CATH ABLATION CATH-D134805 EACH C1732 "$10,213.00 " 278 "$7,149.10 " "$5,106.50 " "$8,170.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195424 CARDIAC CATH ABLATION CATH-D135501 EACH C1733 "$2,690.00 " 278 "$1,883.00 " "$1,345.00 " "$2,152.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195432 CARDIAC CATH ABLATION CATH-D135502 EACH C1733 "$2,690.00 " 278 "$1,883.00 " "$1,345.00 " "$2,152.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195416 CARDIAC CATH ABLATION CATH-D135901 EACH C1733 "$2,690.00 " 278 "$1,883.00 " "$1,345.00 " "$2,152.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193478 CARDIAC CATH ABLATION CATH-D5S06AL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193320 CARDIAC CATH ABLATION CATH-D6BL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193312 CARDIAC CATH ABLATION CATH-D6DL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195085 CARDIAC CATH ABLATION CATH-D6TAL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195093 CARDIAC CATH ABLATION CATH-D6TBL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193411 CARDIAC CATH ABLATION CATH-D6TCAL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195267 CARDIAC CATH ABLATION CATH-D6TCBL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193551 CARDIAC CATH ABLATION CATH-D6TCCL252RT EACH C1730 "$3,130.00 " 278 "$2,191.00 " "$1,565.00 " "$2,504.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195275 CARDIAC CATH ABLATION CATH-D6TCDL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195283 CARDIAC CATH ABLATION CATH-D6TCEL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195101 CARDIAC CATH ABLATION CATH-D6TDL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193338 CARDIAC CATH ABLATION CATH-D7AL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195028 CARDIAC CATH ABLATION CATH-D7BL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195150 CARDIAC CATH ABLATION CATH-D7BTBL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193452 CARDIAC CATH ABLATION CATH-D7BTCBL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195556 CARDIAC CATH ABLATION CATH-D7BTCCL252RT EACH C1733 "$3,130.00 " 278 "$2,191.00 " "$1,565.00 " "$2,504.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195408 CARDIAC CATH ABLATION CATH-D7BTCD5L252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195382 CARDIAC CATH ABLATION CATH-D7BTCDL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195390 CARDIAC CATH ABLATION CATH-D7BTCEL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193486 CARDIAC CATH ABLATION CATH-D7BTCF5L252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195374 CARDIAC CATH ABLATION CATH-D7BTCFL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193536 CARDIAC CATH ABLATION CATH-D7BTCJ5L EACH C1730 "$3,130.00 " 278 "$2,191.00 " "$1,565.00 " "$2,504.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193270 CARDIAC CATH ABLATION CATH-D7BTCJL EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195192 CARDIAC CATH ABLATION CATH-D7BTCL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195325 CARDIAC CATH ABLATION CATH-D7BTD5L252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195168 CARDIAC CATH ABLATION CATH-D7BTDL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195176 CARDIAC CATH ABLATION CATH-D7BTEL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195333 CARDIAC CATH ABLATION CATH-D7BTF5L252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195184 CARDIAC CATH ABLATION CATH-D7BTFL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195002 CARDIAC CATH ABLATION CATH-D7BTG5L EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193239 CARDIAC CATH ABLATION CATH-D7BTGL EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193254 CARDIAC CATH ABLATION CATH-D7BTJ5L EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193247 CARDIAC CATH ABLATION CATH-D7BTJL EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193346 CARDIAC CATH ABLATION CATH-D7CL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195036 CARDIAC CATH ABLATION CATH-D7DL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193353 CARDIAC CATH ABLATION CATH-D7EL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193361 CARDIAC CATH ABLATION CATH-D7FL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193569 CARDIAC CATH ABLATION CATH-D7T270L252RT EACH C1730 "$3,130.00 " 278 "$2,191.00 " "$1,565.00 " "$2,504.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195044 CARDIAC CATH ABLATION CATH-D7TAL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195051 CARDIAC CATH ABLATION CATH-D7TBL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193494 CARDIAC CATH ABLATION CATH-D7TC270L252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195200 CARDIAC CATH ABLATION CATH-D7TCAL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195572 CARDIAC CATH ABLATION CATH-D7TCB8L162RT EACH C1733 "$3,560.00 " 278 "$2,492.00 " "$1,780.00 " "$2,848.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193403 CARDIAC CATH ABLATION CATH-D7TCBG252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195218 CARDIAC CATH ABLATION CATH-D7TCBL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193387 CARDIAC CATH ABLATION CATH-D7TCCG252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195226 CARDIAC CATH ABLATION CATH-D7TCCL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195564 CARDIAC CATH ABLATION CATH-D7TCD8L162RT EACH C1733 "$3,560.00 " 278 "$2,492.00 " "$1,780.00 " "$2,848.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193395 CARDIAC CATH ABLATION CATH-D7TCDG252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195234 CARDIAC CATH ABLATION CATH-D7TCDL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193676 CARDIAC CATH ABLATION CATH-D7TCE8L162RT EACH C1730 "$4,148.00 " 278 "$2,903.60 " "$2,074.00 " "$3,318.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195242 CARDIAC CATH ABLATION CATH-D7TCEL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195580 CARDIAC CATH ABLATION CATH-D7TCF8L162RT EACH C1733 "$3,560.00 " 278 "$2,492.00 " "$1,780.00 " "$2,848.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193544 CARDIAC CATH ABLATION CATH-D7TCFG252RT EACH C1730 "$3,130.00 " 278 "$2,191.00 " "$1,565.00 " "$2,504.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195259 CARDIAC CATH ABLATION CATH-D7TCFL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195598 CARDIAC CATH ABLATION CATH-D7TCJ8L162RT EACH C1733 "$3,560.00 " 278 "$2,492.00 " "$1,780.00 " "$2,848.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195069 CARDIAC CATH ABLATION CATH-D7TCL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193460 CARDIAC CATH ABLATION CATH-D7TCPSL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195077 CARDIAC CATH ABLATION CATH-D7TDL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195119 CARDIAC CATH ABLATION CATH-D7TEL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195127 CARDIAC CATH ABLATION CATH-D7TFL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195291 CARDIAC CATH ABLATION CATH-D8BRCG252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193429 CARDIAC CATH ABLATION CATH-D8BRDL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193437 CARDIAC CATH ABLATION CATH-D8BRFL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193379 CARDIAC CATH ABLATION CATH-D8BTBL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193445 CARDIAC CATH ABLATION CATH-D8BTCBL252RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195341 CARDIAC CATH ABLATION CATH-D8BTCDL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195366 CARDIAC CATH ABLATION CATH-D8BTCEL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195358 CARDIAC CATH ABLATION CATH-D8BTCFL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193296 CARDIAC CATH ABLATION CATH-D8BTCG5L EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193262 CARDIAC CATH ABLATION CATH-D8BTCGL EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195309 CARDIAC CATH ABLATION CATH-D8BTD5L252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195135 CARDIAC CATH ABLATION CATH-D8BTDL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195317 CARDIAC CATH ABLATION CATH-D8BTF5L252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195143 CARDIAC CATH ABLATION CATH-D8BTFL252RT EACH C1733 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195549 CARDIAC CATH ABLATION CATH-D8BTG5L EACH C1733 "$3,130.00 " 278 "$2,191.00 " "$1,565.00 " "$2,504.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193528 CARDIAC CATH ABLATION CATH-D8BTGL EACH C1730 "$3,130.00 " 278 "$2,191.00 " "$1,565.00 " "$2,504.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194492 CARDIAC CATH ABLATION CATH-NI75TCBH EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194500 CARDIAC CATH ABLATION CATH-NI75TCCH EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194518 CARDIAC CATH ABLATION CATH-NI75TCDH EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194526 CARDIAC CATH ABLATION CATH-NI75TCFH EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194534 CARDIAC CATH ABLATION CATH-NI75TCJH EACH C1732 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194385 CARDIAC CATH ABLATION CATH-NR7TCS4Y EACH C1732 "$7,425.00 " 278 "$5,197.50 " "$3,712.50 " "$5,940.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194393 CARDIAC CATH ABLATION CATH-NR7TCS4YU EACH C1732 "$7,425.00 " 278 "$5,197.50 " "$3,712.50 " "$5,940.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194815 CARDIAC CATH ABLATION CATH-NR7TCSIY EACH C1732 "$8,843.00 " 278 "$6,190.10 " "$4,421.50 " "$7,074.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194401 CARDIAC CATH ABLATION CATH-NS7TCB8L174HS EACH C1732 "$7,425.00 " 278 "$5,197.50 " "$3,712.50 " "$5,940.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194302 CARDIAC CATH ABLATION CATH-NS7TCBL174HS EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194419 CARDIAC CATH ABLATION CATH-NS7TCC8L174HS EACH C1732 "$7,425.00 " 278 "$5,197.50 " "$3,712.50 " "$5,940.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194310 CARDIAC CATH ABLATION CATH-NS7TCCL174HS EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194427 CARDIAC CATH ABLATION CATH-NS7TCD8L174HS EACH C1732 "$7,425.00 " 278 "$5,197.50 " "$3,712.50 " "$5,940.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194294 CARDIAC CATH ABLATION CATH-NS7TCDL174HS EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194351 CARDIAC CATH ABLATION CATH-NS7TCDM174HS EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194336 CARDIAC CATH ABLATION CATH-NS7TCEL174HS EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194435 CARDIAC CATH ABLATION CATH-NS7TCF8L174HS EACH C1732 "$7,425.00 " 278 "$5,197.50 " "$3,712.50 " "$5,940.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194328 CARDIAC CATH ABLATION CATH-NS7TCFL174HS EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194443 CARDIAC CATH ABLATION CATH-NS7TCJ8L174HS EACH C1732 "$7,425.00 " 278 "$5,197.50 " "$3,712.50 " "$5,940.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194344 CARDIAC CATH ABLATION CATH-NS7TCJL174HS EACH C1732 "$6,288.00 " 278 "$4,401.60 " "$3,144.00 " "$5,030.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196273 CARDIAC CATH ABLATION CATH-RR6PNY EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 48196257 CARDIAC CATH ABLATION CATH-XRP6H EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 48196265 CARDIAC CATH ABLATION CATH-XRPP8Y EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 48190748 CARDIAC CATH ACCENT DR RF PM-PM2240 EACH C1785 "$8,500.00 " 278 "$5,950.00 " "$4,250.00 " "$6,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195846 CARDIAC CATH ACCESS-301803A EACH C1893 $500.00 278 $350.00 $250.00 $400.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195853 CARDIAC CATH ACCESS-301803M EACH C1893 $500.00 278 $350.00 $250.00 $400.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195887 CARDIAC CATH ACCESS-301803MS EACH C1893 $500.00 278 $350.00 $250.00 $400.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195861 CARDIAC CATH ACCESS-301803P EACH C1893 $500.00 278 $350.00 $250.00 $400.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195879 CARDIAC CATH ACCESS-301805M EACH C1893 $500.00 278 $350.00 $250.00 $400.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195812 CARDIAC CATH ACCESS-D138501 EACH C1766 "$2,983.00 " 278 "$2,088.10 " "$1,491.50 " "$2,386.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195820 CARDIAC CATH ACCESS-D138502 EACH C1766 "$2,983.00 " 278 "$2,088.10 " "$1,491.50 " "$2,386.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195838 CARDIAC CATH ACCESS-D138503 EACH C1766 "$2,983.00 " 278 "$2,088.10 " "$1,491.50 " "$2,386.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196299 CARDIAC CATH ACCESS-D140010 EACH "$2,435.00 " 272 "$1,704.50 " "$1,217.50 " "$1,948.00 " 65% 80% 50% 50% 65% 65% 65% 48196307 CARDIAC CATH ACCESS-D140011 EACH "$2,435.00 " 272 "$1,704.50 " "$1,217.50 " "$1,948.00 " 65% 80% 50% 50% 65% 65% 65% 48193908 CARDIAC CATH ACCESS-F8ENNNNHSB EACH C1732 "$1,285.00 " 278 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196166 CARDIAC CATH ACCESS-FND01900 EACH $500.00 272 $350.00 $250.00 $400.00 65% 80% 50% 50% 65% 65% 65% 48196174 CARDIAC CATH ACCESS-FND01901 EACH $500.00 272 $350.00 $250.00 $400.00 65% 80% 50% 50% 65% 65% 65% 48196158 CARDIAC CATH ACCESS-FND01902 EACH $500.00 272 $350.00 $250.00 $400.00 65% 80% 50% 50% 65% 65% 65% 48196182 CARDIAC CATH ACCESS-FND01903 EACH $500.00 272 $350.00 $250.00 $400.00 65% 80% 50% 50% 65% 65% 65% 48191233 CARDIAC CATH ALLURE CRT-P (IS1) M-PM3222 EACH C2621 "$22,000.00 " 278 "$15,400.00 " "$11,000.00 " "$17,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191225 CARDIAC CATH ALLURE CRT-P (IS1) SYS-PM3222 EACH C2621 "$22,000.00 " 278 "$15,400.00 " "$11,000.00 " "$17,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191209 CARDIAC CATH ALLURE CRT-P (IS1)-PM3222 EACH C2621 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191241 CARDIAC CATH ALLURE Q CRT-P (IS4) M-PM3262 EACH C2621 "$27,625.00 " 278 "$19,337.50 " "$13,812.50 " "$22,100.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191258 CARDIAC CATH ALLURE Q CRT-P (IS4) PM3262 EACH C2621 "$27,625.00 " 278 "$19,337.50 " "$13,812.50 " "$22,100.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191217 CARDIAC CATH ALLURE Q CRT-P (IS4)-PM3262 EACH C2621 "$20,625.00 " 278 "$14,437.50 " "$10,312.50 " "$16,500.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104368 CARDIAC CATH ANGIO/ATHREC 1 ARTERTY EACH "$26,275.00 " 481 "$18,392.50 " "$13,137.50 " "$21,020.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104376 CARDIAC CATH ANGIO/ATHREC 2+ ARTERIES EACH "$32,844.00 " 481 "$22,990.80 " "$16,422.00 " "$26,275.20 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104418 CARDIAC CATH ANGIO/ATHREC W/MULTIPLE STENTS EACH "$50,062.00 " 481 "$35,043.40 " "$25,031.00 " "$40,049.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104400 CARDIAC CATH ANGIO/ATHREC W/SINGLE STENT EACH "$40,049.00 " 481 "$28,034.30 " "$20,024.50 " "$32,039.20 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104392 CARDIAC CATH ANGIO/MULTIPLE STENTS EACH "$32,844.00 " 481 "$22,990.80 " "$16,422.00 " "$26,275.20 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104384 CARDIAC CATH ANGIO/SINGLE STENT EACH "$26,275.00 " 481 "$18,392.50 " "$13,137.50 " "$21,020.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104517 CARDIAC CATH ANGIOGRAM EACH "$7,034.00 " 481 "$4,923.80 " "$3,517.00 " "$5,627.20 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104525 CARDIAC CATH "ANGIOGRAPHY, ILIAC " EACH "$10,662.00 " 323 "$7,463.40 " "$5,331.00 " "$8,529.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 48104350 CARDIAC CATH ANGIOPLST 2+ ARTERIES EACH "$15,890.00 " 481 "$11,123.00 " "$7,945.00 " "$12,712.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104756 CARDIAC CATH ANLYS PACING DUAL W/O PRGM EACH 93283 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104467 CARDIAC CATH AORTIC VALVULOPLASTY EACH "$12,712.00 " 481 "$8,898.40 " "$6,356.00 " "$10,169.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104533 CARDIAC CATH ARTERIOGRAM LOWER EXT RUNOFF EACH "$6,232.00 " 323 "$4,362.40 " "$3,116.00 " "$4,985.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 48191175 CARDIAC CATH ASSURITY DR PM MERLIN-PM2240 EACH C1785 "$9,988.00 " 278 "$6,991.60 " "$4,994.00 " "$7,990.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191183 CARDIAC CATH ASSURITY DR RF PM-PM2240 EACH C1785 "$9,988.00 " 278 "$6,991.60 " "$4,994.00 " "$7,990.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191167 CARDIAC CATH ASSURITY MRI DR RF PM M-PM2272 EACH C1785 "$9,988.00 " 278 "$6,991.60 " "$4,994.00 " "$7,990.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190730 CARDIAC CATH ASSURITY MRI DR RF PM-PM2272 EACH C1785 "$8,500.00 " 278 "$5,950.00 " "$4,250.00 " "$6,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191159 CARDIAC CATH ASSURITY MRI DR RF PM-PM2272 S EACH C1785 "$9,988.00 " 278 "$6,991.60 " "$4,994.00 " "$7,990.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190797 CARDIAC CATH ASSURITY MRI SR RF PM M-PM1272 EACH C1786 "$9,000.00 " 278 "$6,300.00 " "$4,500.00 " "$7,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190714 CARDIAC CATH ASSURITY MRI SR RF PM-PM1272 EACH C1786 "$8,250.00 " 278 "$5,775.00 " "$4,125.00 " "$6,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190789 CARDIAC CATH ASSURITY MRI SR RF PM-PM1272 S EACH C1786 "$9,000.00 " 278 "$6,300.00 " "$4,500.00 " "$7,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190805 CARDIAC CATH ASSURITY SR PM MERLIN-PM1240 EACH C1786 "$9,000.00 " 278 "$6,300.00 " "$4,500.00 " "$7,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190771 CARDIAC CATH ASSURITY SR RF PM SYS-PM1240 EACH C1786 "$9,000.00 " 278 "$6,300.00 " "$4,500.00 " "$7,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190722 CARDIAC CATH ASSURITY SR RF PM-PM1240 EACH C1786 "$8,250.00 " 278 "$5,775.00 " "$4,125.00 " "$6,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110134 CARDIAC CATH BALLOON CATHETER-BVCS6180 EACH $250.00 272 $175.00 $125.00 $200.00 65% 80% 50% 50% 65% 65% 65% 48104475 CARDIAC CATH BIOPSY CARDIAC EACH "$6,232.00 " 481 "$4,362.40 " "$3,116.00 " "$4,985.60 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105449 CARDIAC CATH CABLE CS CATHETER -CB3412CT EACH "$1,150.00 " 272 $805.00 $575.00 $920.00 65% 80% 50% 50% 65% 65% 65% 48105456 CARDIAC CATH CABLE FOR CELSIUS-D130302 EACH "$1,298.00 " 272 $908.60 $649.00 "$1,038.40 " 65% 80% 50% 50% 65% 65% 65% 48105464 CARDIAC CATH CABLE NON-IRRIG NAVISTAR ABLAT EACH "$1,150.00 " 272 $805.00 $575.00 $920.00 65% 80% 50% 50% 65% 65% 65% 48105431 CARDIAC CATH CABLE ST/SF ABLT CATH-CR3434CT EACH "$1,150.00 " 272 $805.00 $575.00 $920.00 65% 80% 50% 50% 65% 65% 65% 48196216 CARDIAC CATH CABLE-C6MR10EPTRS EACH $723.00 272 $506.10 $361.50 $578.40 65% 80% 50% 50% 65% 65% 65% 48196208 CARDIAC CATH CABLE-C6MRMST10SA EACH $723.00 272 $506.10 $361.50 $578.40 65% 80% 50% 50% 65% 65% 65% 48196190 CARDIAC CATH CABLE-C6MRMST4SA EACH $723.00 272 $506.10 $361.50 $578.40 65% 80% 50% 50% 65% 65% 65% 48196232 CARDIAC CATH CABLE-C6OMRMST10SA EACH $723.00 272 $506.10 $361.50 $578.40 65% 80% 50% 50% 65% 65% 65% 48196224 CARDIAC CATH CABLE-C6TMRMST10SA EACH $723.00 272 $506.10 $361.50 $578.40 65% 80% 50% 50% 65% 65% 65% 48195895 CARDIAC CATH CABLE-DI7TCBLRT EACH C2630 "$4,283.00 " 278 "$2,998.10 " "$2,141.50 " "$3,426.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195903 CARDIAC CATH CABLE-DI7TCDLRT EACH C2630 "$4,283.00 " 278 "$2,998.10 " "$2,141.50 " "$3,426.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195911 CARDIAC CATH CABLE-DI7TCFLRT EACH C2630 "$4,283.00 " 278 "$2,998.10 " "$2,141.50 " "$3,426.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195929 CARDIAC CATH CABLE-DI7TCJLRT EACH C2630 "$4,283.00 " 278 "$2,998.10 " "$2,141.50 " "$3,426.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104319 CARDIAC CATH CARDIAC CATHERIZATION PROC EACH "$7,034.00 " 481 "$4,923.80 " "$3,517.00 " "$5,627.20 " 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104541 CARDIAC CATH CATH ABDOMINAL AORTA EACH "$6,232.00 " 323 "$4,362.40 " "$3,116.00 " "$4,985.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 48107213 CARDIAC CATH CATH ATHEREC ROTATION LVL 0 EACH C1724 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107221 CARDIAC CATH CATH ATHEREC ROTATION LVL 1 EACH C1724 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107312 CARDIAC CATH CATH ATHEREC ROTATION LVL 10 EACH C1724 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107239 CARDIAC CATH CATH ATHEREC ROTATION LVL 2 EACH C1724 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107247 CARDIAC CATH CATH ATHEREC ROTATION LVL 3 EACH C1724 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107254 CARDIAC CATH CATH ATHEREC ROTATION LVL 4 EACH C1724 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107262 CARDIAC CATH CATH ATHEREC ROTATION LVL 5 EACH C1724 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107270 CARDIAC CATH CATH ATHEREC ROTATION LVL 6 EACH C1724 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107288 CARDIAC CATH CATH ATHEREC ROTATION LVL 7 EACH C1724 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107296 CARDIAC CATH CATH ATHEREC ROTATION LVL 8 EACH C1724 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107304 CARDIAC CATH CATH ATHEREC ROTATION LVL 9 EACH C1724 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104483 CARDIAC CATH CATH FOR CONGENITAL DEFECT EACH "$7,034.00 " 481 "$4,923.80 " "$3,517.00 " "$5,627.20 " Non Payable 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48107429 CARDIAC CATH CATH INTRAVAS ULTRASOUND LV 10 EACH C1753 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107320 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 0 EACH C1753 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107338 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 1 EACH C1753 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107346 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 2 EACH C1753 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107353 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 3 EACH C1753 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107361 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 4 EACH C1753 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107379 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 5 EACH C1753 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107387 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 6 EACH C1753 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107395 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 7 EACH C1753 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107403 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 8 EACH C1753 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107411 CARDIAC CATH CATH INTRAVAS ULTRASOUND LVL 9 EACH C1753 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107437 CARDIAC CATH CATH THROMB/EMBOLECT LVL 0 EACH C1757 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107445 CARDIAC CATH CATH THROMB/EMBOLECT LVL 1 EACH C1757 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107536 CARDIAC CATH CATH THROMB/EMBOLECT LVL 10 EACH C1757 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107452 CARDIAC CATH CATH THROMB/EMBOLECT LVL 2 EACH C1757 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107460 CARDIAC CATH CATH THROMB/EMBOLECT LVL 3 EACH C1757 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107478 CARDIAC CATH CATH THROMB/EMBOLECT LVL 4 EACH C1757 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107486 CARDIAC CATH CATH THROMB/EMBOLECT LVL 5 EACH C1757 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107494 CARDIAC CATH CATH THROMB/EMBOLECT LVL 6 EACH C1757 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107502 CARDIAC CATH CATH THROMB/EMBOLECT LVL 7 EACH C1757 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107510 CARDIAC CATH CATH THROMB/EMBOLECT LVL 8 EACH C1757 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107528 CARDIAC CATH CATH THROMB/EMBOLECT LVL 9 EACH C1757 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106215 CARDIAC CATH CATHETER ANGIO NONLASER LV 10 EACH C1725 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106116 CARDIAC CATH CATHETER ANGIO NONLASER LVL 0 EACH C1725 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106124 CARDIAC CATH CATHETER ANGIO NONLASER LVL 1 EACH C1725 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106132 CARDIAC CATH CATHETER ANGIO NONLASER LVL 2 EACH C1725 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106140 CARDIAC CATH CATHETER ANGIO NONLASER LVL 3 EACH C1725 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106157 CARDIAC CATH CATHETER ANGIO NONLASER LVL 4 EACH C1725 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106165 CARDIAC CATH CATHETER ANGIO NONLASER LVL 5 EACH C1725 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106173 CARDIAC CATH CATHETER ANGIO NONLASER LVL 6 EACH C1725 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106181 CARDIAC CATH CATHETER ANGIO NONLASER LVL 7 EACH C1725 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106199 CARDIAC CATH CATHETER ANGIO NONLASER LVL 8 EACH C1725 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106207 CARDIAC CATH CATHETER ANGIO NONLASER LVL 9 EACH C1725 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106991 CARDIAC CATH CATHETER GUIDING LVL 0 EACH C1887 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107007 CARDIAC CATH CATHETER GUIDING LVL 1 EACH C1887 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107098 CARDIAC CATH CATHETER GUIDING LVL 10 EACH C1887 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107015 CARDIAC CATH CATHETER GUIDING LVL 2 EACH C1887 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107023 CARDIAC CATH CATHETER GUIDING LVL 3 EACH C1887 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107031 CARDIAC CATH CATHETER GUIDING LVL 4 EACH C1887 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107049 CARDIAC CATH CATHETER GUIDING LVL 5 EACH C1887 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107056 CARDIAC CATH CATHETER GUIDING LVL 6 EACH C1887 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107064 CARDIAC CATH CATHETER GUIDING LVL 7 EACH C1887 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107072 CARDIAC CATH CATHETER GUIDING LVL 8 EACH C1887 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107080 CARDIAC CATH CATHETER GUIDING LVL 9 EACH C1887 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48117824 CARDIAC CATH CCL 3M R7D282CT EACH "$3,118.00 " 272 "$2,182.60 " "$1,559.00 " "$2,494.40 " 65% 80% 50% 50% 65% 65% 65% 48111744 CARDIAC CATH CCL ABBOTT 0048-0003 EACH "$37,500.00 " 272 "$26,250.00 " "$18,750.00 " "$30,000.00 " 65% 80% 50% 50% 65% 65% 65% 48197289 CARDIAC CATH CCL ABBOTT 1001780-HC EACH $190.00 272 $133.00 $95.00 $152.00 65% 80% 50% 50% 65% 65% 65% 48197297 CARDIAC CATH CCL ABBOTT 1003309H EACH $190.00 272 $133.00 $95.00 $152.00 65% 80% 50% 50% 65% 65% 65% 48197305 CARDIAC CATH CCL ABBOTT 1005357H EACH $190.00 272 $133.00 $95.00 $152.00 65% 80% 50% 50% 65% 65% 65% 48197313 CARDIAC CATH CCL ABBOTT 1012270-12 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48197321 CARDIAC CATH CCL ABBOTT 1012270-15 EACH C1725 $313.00 278 $219.10 $156.50 $250.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197339 CARDIAC CATH CCL ABBOTT 1012272-12 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48197347 CARDIAC CATH CCL ABBOTT 1012272-15 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48197354 CARDIAC CATH CCL ABBOTT 1012274-12 EACH C1725 $375.00 278 $262.50 $187.50 $300.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197362 CARDIAC CATH CCL ABBOTT 1012274-15 EACH C1725 $313.00 278 $219.10 $156.50 $250.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197370 CARDIAC CATH CCL ABBOTT 1012276-12 EACH C1725 $313.00 278 $219.10 $156.50 $250.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197388 CARDIAC CATH CCL ABBOTT 1012278-12 EACH C1725 $313.00 278 $219.10 $156.50 $250.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197396 CARDIAC CATH CCL ABBOTT 1012403-12A EACH C1725 $313.00 278 $219.10 $156.50 $250.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197404 CARDIAC CATH CCL ABBOTT 1012403-15A EACH C1725 $313.00 278 $219.10 $156.50 $250.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197412 CARDIAC CATH CCL ABBOTT 1012405-12 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48197420 CARDIAC CATH CCL ABBOTT 1012405-15 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48197438 CARDIAC CATH CCL ABBOTT 1013317 EACH $190.00 272 $133.00 $95.00 $152.00 65% 80% 50% 50% 65% 65% 65% 48197453 CARDIAC CATH CCL ABBOTT 1044595 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197461 CARDIAC CATH CCL ABBOTT 1550225-08 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197479 CARDIAC CATH CCL ABBOTT 1550225-12 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197487 CARDIAC CATH CCL ABBOTT 1550225-15 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197495 CARDIAC CATH CCL ABBOTT 1550225-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197503 CARDIAC CATH CCL ABBOTT 1550225-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197511 CARDIAC CATH CCL ABBOTT 1550225-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197529 CARDIAC CATH CCL ABBOTT 1550225-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197537 CARDIAC CATH CCL ABBOTT 1550250-08 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197545 CARDIAC CATH CCL ABBOTT 1550250-12 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197552 CARDIAC CATH CCL ABBOTT 1550250-15 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197560 CARDIAC CATH CCL ABBOTT 1550250-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197578 CARDIAC CATH CCL ABBOTT 1550250-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197586 CARDIAC CATH CCL ABBOTT 1550250-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197594 CARDIAC CATH CCL ABBOTT 1550250-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197602 CARDIAC CATH CCL ABBOTT 1550250-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197610 CARDIAC CATH CCL ABBOTT 1550275-12 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197628 CARDIAC CATH CCL ABBOTT 1550275-15 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197636 CARDIAC CATH CCL ABBOTT 1550275-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197644 CARDIAC CATH CCL ABBOTT 1550275-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197651 CARDIAC CATH CCL ABBOTT 1550275-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197669 CARDIAC CATH CCL ABBOTT 1550275-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197677 CARDIAC CATH CCL ABBOTT 1550275-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197685 CARDIAC CATH CCL ABBOTT 1550300-12 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197693 CARDIAC CATH CCL ABBOTT 1550300-15 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197701 CARDIAC CATH CCL ABBOTT 1550300-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197719 CARDIAC CATH CCL ABBOTT 1550300-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197727 CARDIAC CATH CCL ABBOTT 1550300-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197735 CARDIAC CATH CCL ABBOTT 1550300-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197743 CARDIAC CATH CCL ABBOTT 1550300-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197750 CARDIAC CATH CCL ABBOTT 1550325-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197768 CARDIAC CATH CCL ABBOTT 1550325-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197776 CARDIAC CATH CCL ABBOTT 1550325-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197784 CARDIAC CATH CCL ABBOTT 1550325-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197792 CARDIAC CATH CCL ABBOTT 1550325-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197800 CARDIAC CATH CCL ABBOTT 1550350-12 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197818 CARDIAC CATH CCL ABBOTT 1550350-15 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197826 CARDIAC CATH CCL ABBOTT 1550350-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197834 CARDIAC CATH CCL ABBOTT 1550350-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197842 CARDIAC CATH CCL ABBOTT 1550350-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197859 CARDIAC CATH CCL ABBOTT 1550350-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197867 CARDIAC CATH CCL ABBOTT 1550350-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197875 CARDIAC CATH CCL ABBOTT 1550400-08 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197883 CARDIAC CATH CCL ABBOTT 1550400-12 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197891 CARDIAC CATH CCL ABBOTT 1550400-15 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197909 CARDIAC CATH CCL ABBOTT 1550400-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197917 CARDIAC CATH CCL ABBOTT 1550400-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197925 CARDIAC CATH CCL ABBOTT 1550400-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197933 CARDIAC CATH CCL ABBOTT 1550400-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48197941 CARDIAC CATH CCL ABBOTT 1550400-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48198030 CARDIAC CATH CCL ABBOTT 22260 EACH $190.00 272 $133.00 $95.00 $152.00 65% 80% 50% 50% 65% 65% 65% 48199905 CARDIAC CATH CCL ABBOTT 401980 EACH $240.00 272 $168.00 $120.00 $192.00 65% 80% 50% 50% 65% 65% 65% 48199913 CARDIAC CATH CCL ABBOTT 401981 EACH $240.00 272 $168.00 $120.00 $192.00 65% 80% 50% 50% 65% 65% 65% 48199921 CARDIAC CATH CCL ABBOTT 401982 EACH $240.00 272 $168.00 $120.00 $192.00 65% 80% 50% 50% 65% 65% 65% 48199939 CARDIAC CATH CCL ABBOTT 401983 EACH $240.00 272 $168.00 $120.00 $192.00 65% 80% 50% 50% 65% 65% 65% 48198105 CARDIAC CATH CCL ABBOTT 7121-65 EACH "$9,500.00 " 272 "$6,650.00 " "$4,750.00 " "$7,600.00 " 65% 80% 50% 50% 65% 65% 65% 48199640 CARDIAC CATH CCL ABBOTT 9-9DA-006 EACH "$12,093.00 " 272 "$8,465.10 " "$6,046.50 " "$9,674.40 " 65% 80% 50% 50% 65% 65% 65% 48110837 CARDIAC CATH CCL ABBOTT 9-ASD-004 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110845 CARDIAC CATH CCL ABBOTT 9-ASD-005 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110852 CARDIAC CATH CCL ABBOTT 9-ASD-006 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110860 CARDIAC CATH CCL ABBOTT 9-ASD-007 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110878 CARDIAC CATH CCL ABBOTT 9-ASD-008 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110886 CARDIAC CATH CCL ABBOTT 9-ASD-009 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110894 CARDIAC CATH CCL ABBOTT 9-ASD-010 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110902 CARDIAC CATH CCL ABBOTT 9-ASD-011 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110910 CARDIAC CATH CCL ABBOTT 9-ASD-012 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110928 CARDIAC CATH CCL ABBOTT 9-ASD-013 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110936 CARDIAC CATH CCL ABBOTT 9-ASD-014 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110944 CARDIAC CATH CCL ABBOTT 9-ASD-015 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110951 CARDIAC CATH CCL ABBOTT 9-ASD-016 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110969 CARDIAC CATH CCL ABBOTT 9-ASD-017 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110977 CARDIAC CATH CCL ABBOTT 9-ASD-018 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110985 CARDIAC CATH CCL ABBOTT 9-ASD-019 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48110993 CARDIAC CATH CCL ABBOTT 9-ASD-020 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111009 CARDIAC CATH CCL ABBOTT 9-ASD-022 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111017 CARDIAC CATH CCL ABBOTT 9-ASD-024 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111025 CARDIAC CATH CCL ABBOTT 9-ASD-026 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48199657 CARDIAC CATH CCL ABBOTT 9-ASD-028 EACH "$18,603.00 " 272 "$13,022.10 " "$9,301.50 " "$14,882.40 " 65% 80% 50% 50% 65% 65% 65% 48111033 CARDIAC CATH CCL ABBOTT 9-ASD-030 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111041 CARDIAC CATH CCL ABBOTT 9-ASD-032 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111058 CARDIAC CATH CCL ABBOTT 9-ASD-034 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111066 CARDIAC CATH CCL ABBOTT 9-ASD-036 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111074 CARDIAC CATH CCL ABBOTT 9-ASD-038 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111082 CARDIAC CATH CCL ABBOTT 9-ASD-MF-018 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111090 CARDIAC CATH CCL ABBOTT 9-ASD-MF-025 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111108 CARDIAC CATH CCL ABBOTT 9-ASD-MF-030 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111116 CARDIAC CATH CCL ABBOTT 9-ASD-MF-035 EACH "$18,602.50 " 272 "$13,021.75 " "$9,301.25 " "$14,882.00 " 65% 80% 50% 50% 65% 65% 65% 48111405 CARDIAC CATH CCL ABBOTT 9-ASD-SZP EACH $15.00 272 $10.50 $7.50 $12.00 65% 80% 50% 50% 65% 65% 65% 48199723 CARDIAC CATH CCL ABBOTT 9-ATV09F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48199749 CARDIAC CATH CCL ABBOTT 9-ATV10F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111546 CARDIAC CATH CCL ABBOTT 9-EITV06F180/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111553 CARDIAC CATH CCL ABBOTT 9-EITV08F180/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111538 CARDIAC CATH CCL ABBOTT 9-EITV09F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48199764 CARDIAC CATH CCL ABBOTT 9-EITV12F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111363 CARDIAC CATH CCL ABBOTT 9-GW-001 EACH $157.50 272 $110.25 $78.75 $126.00 65% 80% 50% 50% 65% 65% 65% 48199681 CARDIAC CATH CCL ABBOTT 9-GW-001 EACH $158.00 272 $110.60 $79.00 $126.40 65% 80% 50% 50% 65% 65% 65% 48111371 CARDIAC CATH CCL ABBOTT 9-GW-002 EACH $157.50 272 $110.25 $78.75 $126.00 65% 80% 50% 50% 65% 65% 65% 48111389 CARDIAC CATH CCL ABBOTT 9-GW-003 EACH $157.50 272 $110.25 $78.75 $126.00 65% 80% 50% 50% 65% 65% 65% 48111397 CARDIAC CATH CCL ABBOTT 9-GW-004 EACH $157.50 272 $110.25 $78.75 $126.00 65% 80% 50% 50% 65% 65% 65% 48111488 CARDIAC CATH CCL ABBOTT 9-ITV05F180/60 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111496 CARDIAC CATH CCL ABBOTT 9-ITV06F180/60 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111504 CARDIAC CATH CCL ABBOTT 9-ITV06F180/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111413 CARDIAC CATH CCL ABBOTT 9-ITV06F45/60 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48199731 CARDIAC CATH CCL ABBOTT 9-ITV07F180/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111421 CARDIAC CATH CCL ABBOTT 9-ITV07F45/60 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111439 CARDIAC CATH CCL ABBOTT 9-ITV07F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111512 CARDIAC CATH CCL ABBOTT 9-ITV08F180/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111447 CARDIAC CATH CCL ABBOTT 9-ITV08F45/60 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111454 CARDIAC CATH CCL ABBOTT 9-ITV08F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111520 CARDIAC CATH CCL ABBOTT 9-ITV09F180/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48199756 CARDIAC CATH CCL ABBOTT 9-ITV09F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111462 CARDIAC CATH CCL ABBOTT 9-ITV10F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111470 CARDIAC CATH CCL ABBOTT 9-ITV12F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48199715 CARDIAC CATH CCL ABBOTT 9ITV12F45/80 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111124 CARDIAC CATH CCL ABBOTT 9-PDA-003 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111132 CARDIAC CATH CCL ABBOTT 9-PDA-004 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111140 CARDIAC CATH CCL ABBOTT 9-PDA-005 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111157 CARDIAC CATH CCL ABBOTT 9-PDA-006 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111165 CARDIAC CATH CCL ABBOTT 9-PDA-007 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111173 CARDIAC CATH CCL ABBOTT 9-PDA2-03-04 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111181 CARDIAC CATH CCL ABBOTT 9-PDA2-03-06 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111199 CARDIAC CATH CCL ABBOTT 9-PDA2-04-04 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111207 CARDIAC CATH CCL ABBOTT 9-PDA2-04-06 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111223 CARDIAC CATH CCL ABBOTT 9-PDA2-05-06 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111231 CARDIAC CATH CCL ABBOTT 9-PDA2-06-04 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111249 CARDIAC CATH CCL ABBOTT 9-PDA2-06-06 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111736 CARDIAC CATH CCL ABBOTT 9-PFO-018 EACH "$24,987.50 " 272 "$17,491.25 " "$12,493.75 " "$19,990.00 " 65% 80% 50% 50% 65% 65% 65% 48199665 CARDIAC CATH CCL ABBOTT 9-PFO-025 EACH "$24,988.00 " 272 "$17,491.60 " "$12,494.00 " "$19,990.40 " 65% 80% 50% 50% 65% 65% 65% 48111330 CARDIAC CATH CCL ABBOTT 9-SB-018 EACH $917.50 272 $642.25 $458.75 $734.00 65% 80% 50% 50% 65% 65% 65% 48111348 CARDIAC CATH CCL ABBOTT 9-SB-024 EACH $917.50 272 $642.25 $458.75 $734.00 65% 80% 50% 50% 65% 65% 65% 48111355 CARDIAC CATH CCL ABBOTT 9-SB-034 EACH $917.50 272 $642.25 $458.75 $734.00 65% 80% 50% 50% 65% 65% 65% 48199707 CARDIAC CATH CCL ABBOTT 9-SZB-024 EACH $918.00 272 $642.60 $459.00 $734.40 65% 80% 50% 50% 65% 65% 65% 48199699 CARDIAC CATH CCL ABBOTT 9-SZB-034 EACH $918.00 272 $642.60 $459.00 $734.40 65% 80% 50% 50% 65% 65% 65% 48111603 CARDIAC CATH CCL ABBOTT 9-TV2-05F120 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111611 CARDIAC CATH CCL ABBOTT 9-TV2-06F120 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111629 CARDIAC CATH CCL ABBOTT 9-TV2-07F120 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111637 CARDIAC CATH CCL ABBOTT 9-TV45X45-09F-080 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111686 CARDIAC CATH CCL ABBOTT 9-TV45X45-09F-100 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111645 CARDIAC CATH CCL ABBOTT 9-TV45X45-10F-080 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111652 CARDIAC CATH CCL ABBOTT 9-TV45X45-12F-080 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111702 CARDIAC CATH CCL ABBOTT 9-TV45X45-12F-100 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111660 CARDIAC CATH CCL ABBOTT 9-TV45X45-13F-080 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111710 CARDIAC CATH CCL ABBOTT 9-TV45X45-13F-100 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111678 CARDIAC CATH CCL ABBOTT 9-TV45X45-14F-080 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111728 CARDIAC CATH CCL ABBOTT 9-TV45X45-14F-100 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111561 CARDIAC CATH CCL ABBOTT 9-TVLP4F90/060 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111579 CARDIAC CATH CCL ABBOTT 9-TVLP4F90/080 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111587 CARDIAC CATH CCL ABBOTT 9-TVLP5F90/060 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111595 CARDIAC CATH CCL ABBOTT 9-TVLP5F90/080 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111256 CARDIAC CATH CCL ABBOTT 9-VSD-MUSC-004 EACH "$22,395.00 " 272 "$15,676.50 " "$11,197.50 " "$17,916.00 " 65% 80% 50% 50% 65% 65% 65% 48111264 CARDIAC CATH CCL ABBOTT 9-VSD-MUSC-006 EACH "$22,395.00 " 272 "$15,676.50 " "$11,197.50 " "$17,916.00 " 65% 80% 50% 50% 65% 65% 65% 48111272 CARDIAC CATH CCL ABBOTT 9-VSD-MUSC-008 EACH "$22,395.00 " 272 "$15,676.50 " "$11,197.50 " "$17,916.00 " 65% 80% 50% 50% 65% 65% 65% 48111298 CARDIAC CATH CCL ABBOTT 9-VSD-MUSC-012 EACH "$22,395.00 " 272 "$15,676.50 " "$11,197.50 " "$17,916.00 " 65% 80% 50% 50% 65% 65% 65% 48111306 CARDIAC CATH CCL ABBOTT 9-VSD-MUSC-014 EACH "$22,395.00 " 272 "$15,676.50 " "$11,197.50 " "$17,916.00 " 65% 80% 50% 50% 65% 65% 65% 48111314 CARDIAC CATH CCL ABBOTT 9-VSD-MUSC-016 EACH "$22,395.00 " 272 "$15,676.50 " "$11,197.50 " "$17,916.00 " 65% 80% 50% 50% 65% 65% 65% 48111322 CARDIAC CATH CCL ABBOTT 9-VSD-MUSC-018 EACH "$22,395.00 " 272 "$15,676.50 " "$11,197.50 " "$17,916.00 " 65% 80% 50% 50% 65% 65% 65% 48117014 CARDIAC CATH CCL ABBOTT CC 1012272-20 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48117022 CARDIAC CATH CCL ABBOTT CC 1012274-20 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48117030 CARDIAC CATH CCL ABBOTT CC 1012275-15 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48117048 CARDIAC CATH CCL ABBOTT CC 1550300-08 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117055 CARDIAC CATH CCL ABBOTT CC 1550325-12 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117063 CARDIAC CATH CCL ABBOTT CC 1550325-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117071 CARDIAC CATH CCL ABBOTT CC 1804225-15 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117089 CARDIAC CATH CCL ABBOTT CC 1804225-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117097 CARDIAC CATH CCL ABBOTT CC 1804225-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117105 CARDIAC CATH CCL ABBOTT CC 1804250-12 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117113 CARDIAC CATH CCL ABBOTT CC 1804250-15 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117121 CARDIAC CATH CCL ABBOTT CC 1804250-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117139 CARDIAC CATH CCL ABBOTT CC 1804250-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117147 CARDIAC CATH CCL ABBOTT CC 1804250-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117154 CARDIAC CATH CCL ABBOTT CC 1804250-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117162 CARDIAC CATH CCL ABBOTT CC 1804250-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117170 CARDIAC CATH CCL ABBOTT CC 1804275-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117188 CARDIAC CATH CCL ABBOTT CC 1804275-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117196 CARDIAC CATH CCL ABBOTT CC 1804275-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117204 CARDIAC CATH CCL ABBOTT CC 1804275-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117212 CARDIAC CATH CCL ABBOTT CC 1804300-15 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117220 CARDIAC CATH CCL ABBOTT CC 1804300-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117238 CARDIAC CATH CCL ABBOTT CC 1804300-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117246 CARDIAC CATH CCL ABBOTT CC 1804300-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117253 CARDIAC CATH CCL ABBOTT CC 1804300-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117261 CARDIAC CATH CCL ABBOTT CC 1804300-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117279 CARDIAC CATH CCL ABBOTT CC 1804325-08 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117287 CARDIAC CATH CCL ABBOTT CC 1804325-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117295 CARDIAC CATH CCL ABBOTT CC 1804325-38 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117303 CARDIAC CATH CCL ABBOTT CC 1804350-12 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117311 CARDIAC CATH CCL ABBOTT CC 1804350-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117329 CARDIAC CATH CCL ABBOTT CC 1804350-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117337 CARDIAC CATH CCL ABBOTT CC 1804350-33 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117345 CARDIAC CATH CCL ABBOTT CC 1804400-18 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117352 CARDIAC CATH CCL ABBOTT CC 1804400-23 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48117360 CARDIAC CATH CCL ABBOTT CC 1804400-28 EACH "$2,238.00 " 272 "$1,566.60 " "$1,119.00 " "$1,790.40 " 65% 80% 50% 50% 65% 65% 65% 48116990 CARDIAC CATH CCL ABBOTT CC 408310 EACH "$2,518.00 " 272 "$1,762.60 " "$1,259.00 " "$2,014.40 " 65% 80% 50% 50% 65% 65% 65% 48117485 CARDIAC CATH CCL ABBOTT CC 9-ASD-032 EACH "$18,603.00 " 272 "$13,022.10 " "$9,301.50 " "$14,882.40 " 65% 80% 50% 50% 65% 65% 65% 48110647 CARDIAC CATH CCL ABBOTT CDDRA300Q EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48110670 CARDIAC CATH CCL ABBOTT CDDRA300Q SYSCELL EACH "$25,056.00 " 272 "$17,539.20 " "$12,528.00 " "$20,044.80 " 65% 80% 50% 50% 65% 65% 65% 48110688 CARDIAC CATH CCL ABBOTT CDDRA500Q SYSCELL EACH "$27,504.00 " 272 "$19,252.80 " "$13,752.00 " "$22,003.20 " 65% 80% 50% 50% 65% 65% 65% 48110696 CARDIAC CATH CCL ABBOTT CDHFA300Q EACH "$33,870.00 " 272 "$23,709.00 " "$16,935.00 " "$27,096.00 " 65% 80% 50% 50% 65% 65% 65% 48110720 CARDIAC CATH CCL ABBOTT CDHFA300Q SYSCELL EACH "$39,630.00 " 272 "$27,741.00 " "$19,815.00 " "$31,704.00 " 65% 80% 50% 50% 65% 65% 65% 48110704 CARDIAC CATH CCL ABBOTT CDHFA300Q SYSTEM EACH "$39,630.00 " 272 "$27,741.00 " "$19,815.00 " "$31,704.00 " 65% 80% 50% 50% 65% 65% 65% 48110738 CARDIAC CATH CCL ABBOTT CDHFA500Q SYSCELL EACH "$40,839.00 " 272 "$28,587.30 " "$20,419.50 " "$32,671.20 " 65% 80% 50% 50% 65% 65% 65% 48110712 CARDIAC CATH CCL ABBOTT CDHFA500Q SYSTEM EACH "$40,839.00 " 272 "$28,587.30 " "$20,419.50 " "$32,671.20 " 65% 80% 50% 50% 65% 65% 65% 48110639 CARDIAC CATH CCL ABBOTT CDVRA300Q EACH "$36,960.00 " 272 "$25,872.00 " "$18,480.00 " "$29,568.00 " 65% 80% 50% 50% 65% 65% 65% 48110654 CARDIAC CATH CCL ABBOTT CDVRA300Q SYSTEM EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48110662 CARDIAC CATH CCL ABBOTT CDVRA500Q SYSTEM EACH "$27,504.00 " 272 "$19,252.80 " "$13,752.00 " "$22,003.20 " 65% 80% 50% 50% 65% 65% 65% 48110605 CARDIAC CATH CCL ABBOTT CM PATIENT SYSTEM EACH "$32,250.00 " 272 "$22,575.00 " "$16,125.00 " "$25,800.00 " 65% 80% 50% 50% 65% 65% 65% 48110613 CARDIAC CATH CCL ABBOTT CM3000 EACH "$23,750.00 " 272 "$16,625.00 " "$11,875.00 " "$19,000.00 " 65% 80% 50% 50% 65% 65% 65% 48110621 CARDIAC CATH CCL ABBOTT CM3040 EACH $50.00 272 $35.00 $25.00 $40.00 65% 80% 50% 50% 65% 65% 65% 48104160 CARDIAC CATH CCL ABBOTT CRITCARE 1012271-15 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48104178 CARDIAC CATH CCL ABBOTT CRITCARE 1012771-12 EACH $313.00 272 $219.10 $156.50 $250.40 65% 80% 50% 50% 65% 65% 65% 48198493 CARDIAC CATH CCL ABBOTT DS06001 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48198501 CARDIAC CATH CCL ABBOTT DS06003 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48198519 CARDIAC CATH CCL ABBOTT DS2N027-59 SUB-90 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48199947 CARDIAC CATH CCL ABBOTT IBI-85931 EACH $598.00 272 $418.60 $299.00 $478.40 65% 80% 50% 50% 65% 65% 65% 48105704 CARDIAC CATH CCL ABBOTT LDA220Q-58 EACH "$9,500.00 " 272 "$6,650.00 " "$4,750.00 " "$7,600.00 " 65% 80% 50% 50% 65% 65% 65% 48110829 CARDIAC CATH CCL ABBOTT MCG40100 EACH "$75,000.00 " 272 "$52,500.00 " "$37,500.00 " "$60,000.00 " 65% 80% 50% 50% 65% 65% 65% 48111215 CARDIAC CATH CCL ABBOTT9-PDA2-05-04 EACH "$12,092.50 " 272 "$8,464.75 " "$6,046.25 " "$9,674.00 " 65% 80% 50% 50% 65% 65% 65% 48111694 CARDIAC CATH CCL ABBOTT9-TV45X45-10F-100 EACH "$2,170.00 " 272 "$1,519.00 " "$1,085.00 " "$1,736.00 " 65% 80% 50% 50% 65% 65% 65% 48111280 CARDIAC CATH CCL ABBOTT9-VSD-MUSC-010 EACH "$22,395.00 " 272 "$15,676.50 " "$11,197.50 " "$17,916.00 " 65% 80% 50% 50% 65% 65% 65% 48112148 CARDIAC CATH CCL ACIST ATX SIMPLICITY SET EACH $238.00 272 $166.60 $119.00 $190.40 65% 80% 50% 50% 65% 65% 65% 48112130 CARDIAC CATH CCL ACIST MULTIUSE SYRINGE KIT EACH $113.00 272 $79.10 $56.50 $90.40 65% 80% 50% 50% 65% 65% 65% 48104152 CARDIAC CATH CCL ANGIOTECH 014645 EACH $113.00 272 $79.10 $56.50 $90.40 65% 80% 50% 50% 65% 65% 65% 48116966 CARDIAC CATH CCL ARGON 395510 EACH $903.00 272 $632.10 $451.50 $722.40 65% 80% 50% 50% 65% 65% 65% 48105696 CARDIAC CATH CCL ARGON 395798 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48117766 CARDIAC CATH CCL BAYLIS NRG-E-HF-89-C1 EACH $638.00 272 $446.60 $319.00 $510.40 65% 80% 50% 50% 65% 65% 65% 48116479 CARDIAC CATH CCL BIOSENSE 08255790 EACH "$7,845.00 " 272 "$5,491.50 " "$3,922.50 " "$6,276.00 " 65% 80% 50% 50% 65% 65% 65% 48116487 CARDIAC CATH CCL BIOSENSE 10043342 EACH "$7,845.00 " 272 "$5,491.50 " "$3,922.50 " "$6,276.00 " 65% 80% 50% 50% 65% 65% 65% 48116495 CARDIAC CATH CCL BIOSENSE 10135910 EACH "$7,845.00 " 272 "$5,491.50 " "$3,922.50 " "$6,276.00 " 65% 80% 50% 50% 65% 65% 65% 48116461 CARDIAC CATH CCL BIOSENSE 10135936 EACH "$7,845.00 " 272 "$5,491.50 " "$3,922.50 " "$6,276.00 " 65% 80% 50% 50% 65% 65% 65% 48116552 CARDIAC CATH CCL BIOSENSE 10438577 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48116586 CARDIAC CATH CCL BIOSENSE 10439011 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48116545 CARDIAC CATH CCL BIOSENSE 10439072 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48116594 CARDIAC CATH CCL BIOSENSE 10439236 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48113153 CARDIAC CATH CCL BIOSENSE 107832RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113880 CARDIAC CATH CCL BIOSENSE 107875S EACH "$1,903.00 " 272 "$1,332.10 " $951.50 "$1,522.40 " 65% 80% 50% 50% 65% 65% 65% 48113203 CARDIAC CATH CCL BIOSENSE 107890S EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113716 CARDIAC CATH CCL BIOSENSE 1079251S EACH "$1,020.00 " 272 $714.00 $510.00 $816.00 65% 80% 50% 50% 65% 65% 65% 48113724 CARDIAC CATH CCL BIOSENSE 1079254S EACH "$1,020.00 " 272 $714.00 $510.00 $816.00 65% 80% 50% 50% 65% 65% 65% 48113609 CARDIAC CATH CCL BIOSENSE 1079257S EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48114961 CARDIAC CATH CCL BIOSENSE 1085122RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114938 CARDIAC CATH CCL BIOSENSE 1086259RT EACH $533.00 272 $373.10 $266.50 $426.40 65% 80% 50% 50% 65% 65% 65% 48114912 CARDIAC CATH CCL BIOSENSE 1086577S EACH $533.00 272 $373.10 $266.50 $426.40 65% 80% 50% 50% 65% 65% 65% 48115265 CARDIAC CATH CCL BIOSENSE 1086778S EACH "$1,218.00 " 272 $852.60 $609.00 $974.40 65% 80% 50% 50% 65% 65% 65% 48115034 CARDIAC CATH CCL BIOSENSE 1088124S EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115182 CARDIAC CATH CCL BIOSENSE 112434RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48115190 CARDIAC CATH CCL BIOSENSE 112436RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48115240 CARDIAC CATH CCL BIOSENSE 112442S EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48115257 CARDIAC CATH CCL BIOSENSE 112449S EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114318 CARDIAC CATH CCL BIOSENSE 116008RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48113146 CARDIAC CATH CCL BIOSENSE 116409RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48116453 CARDIAC CATH CCL BIOSENSE 118330S EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48116404 CARDIAC CATH CCL BIOSENSE 118331S EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48116412 CARDIAC CATH CCL BIOSENSE 118332S EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48116420 CARDIAC CATH CCL BIOSENSE 118431S EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48116438 CARDIAC CATH CCL BIOSENSE 118432S EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48116446 CARDIAC CATH CCL BIOSENSE 118435S EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48114011 CARDIAC CATH CCL BIOSENSE 122071S EACH "$3,790.00 " 272 "$2,653.00 " "$1,895.00 " "$3,032.00 " 65% 80% 50% 50% 65% 65% 65% 48113997 CARDIAC CATH CCL BIOSENSE 122072S EACH "$3,790.00 " 272 "$2,653.00 " "$1,895.00 " "$3,032.00 " 65% 80% 50% 50% 65% 65% 65% 48113948 CARDIAC CATH CCL BIOSENSE 122073S EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114045 CARDIAC CATH CCL BIOSENSE 123703S EACH "$4,868.00 " 272 "$3,407.60 " "$2,434.00 " "$3,894.40 " 65% 80% 50% 50% 65% 65% 65% 48116693 CARDIAC CATH CCL BIOSENSE 301803A EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116651 CARDIAC CATH CCL BIOSENSE 301803M EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116669 CARDIAC CATH CCL BIOSENSE 301803MS EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116701 CARDIAC CATH CCL BIOSENSE 301803P EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116677 CARDIAC CATH CCL BIOSENSE 301805M EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48113773 CARDIAC CATH CCL BIOSENSE BD710DF282RTS EACH "$1,623.00 " 272 "$1,136.10 " $811.50 "$1,298.40 " 65% 80% 50% 50% 65% 65% 65% 48113765 CARDIAC CATH CCL BIOSENSE BD710FJ282RTS EACH "$1,623.00 " 272 "$1,136.10 " $811.50 "$1,298.40 " 65% 80% 50% 50% 65% 65% 65% 48112742 CARDIAC CATH CCL BIOSENSE BD7TCDD4L EACH "$2,560.00 " 272 "$1,792.00 " "$1,280.00 " "$2,048.00 " 65% 80% 50% 50% 65% 65% 65% 48112858 CARDIAC CATH CCL BIOSENSE BD7TCDD8L EACH "$3,650.00 " 272 "$2,555.00 " "$1,825.00 " "$2,920.00 " 65% 80% 50% 50% 65% 65% 65% 48112866 CARDIAC CATH CCL BIOSENSE BD7TCDF8L EACH "$3,650.00 " 272 "$2,555.00 " "$1,825.00 " "$2,920.00 " 65% 80% 50% 50% 65% 65% 65% 48112775 CARDIAC CATH CCL BIOSENSE BD7TCFF4L EACH "$2,560.00 " 272 "$1,792.00 " "$1,280.00 " "$2,048.00 " 65% 80% 50% 50% 65% 65% 65% 48112833 CARDIAC CATH CCL BIOSENSE BD7TCFF8L EACH "$3,650.00 " 272 "$2,555.00 " "$1,825.00 " "$2,920.00 " 65% 80% 50% 50% 65% 65% 65% 48112759 CARDIAC CATH CCL BIOSENSE BD7TCFJ4L EACH "$2,560.00 " 272 "$1,792.00 " "$1,280.00 " "$2,048.00 " 65% 80% 50% 50% 65% 65% 65% 48112874 CARDIAC CATH CCL BIOSENSE BD7TCFJ8L EACH "$3,650.00 " 272 "$2,555.00 " "$1,825.00 " "$2,920.00 " 65% 80% 50% 50% 65% 65% 65% 48112767 CARDIAC CATH CCL BIOSENSE BD7TCJJ4L EACH "$2,560.00 " 272 "$1,792.00 " "$1,280.00 " "$2,048.00 " 65% 80% 50% 50% 65% 65% 65% 48112841 CARDIAC CATH CCL BIOSENSE BD7TCJJ8L EACH "$3,650.00 " 272 "$2,555.00 " "$1,825.00 " "$2,920.00 " 65% 80% 50% 50% 65% 65% 65% 48112783 CARDIAC CATH CCL BIOSENSE BD7TDD4L EACH "$2,560.00 " 272 "$1,792.00 " "$1,280.00 " "$2,048.00 " 65% 80% 50% 50% 65% 65% 65% 48112825 CARDIAC CATH CCL BIOSENSE BD7TDF4L EACH "$2,560.00 " 272 "$1,792.00 " "$1,280.00 " "$2,048.00 " 65% 80% 50% 50% 65% 65% 65% 48112791 CARDIAC CATH CCL BIOSENSE BD7TFF4L EACH "$2,560.00 " 272 "$1,792.00 " "$1,280.00 " "$2,048.00 " 65% 80% 50% 50% 65% 65% 65% 48112817 CARDIAC CATH CCL BIOSENSE BD7TFJ4L EACH "$2,560.00 " 272 "$1,792.00 " "$1,280.00 " "$2,048.00 " 65% 80% 50% 50% 65% 65% 65% 48112809 CARDIAC CATH CCL BIOSENSE BD7TJJ4L EACH "$2,560.00 " 272 "$1,792.00 " "$1,280.00 " "$2,048.00 " 65% 80% 50% 50% 65% 65% 65% 48112940 CARDIAC CATH CCL BIOSENSE BDI35BBRT EACH "$4,798.00 " 272 "$3,358.60 " "$2,399.00 " "$3,838.40 " 65% 80% 50% 50% 65% 65% 65% 48112999 CARDIAC CATH CCL BIOSENSE BDI35BDRT EACH "$4,798.00 " 272 "$3,358.60 " "$2,399.00 " "$3,838.40 " 65% 80% 50% 50% 65% 65% 65% 48112981 CARDIAC CATH CCL BIOSENSE BDI35BFRT EACH "$4,798.00 " 272 "$3,358.60 " "$2,399.00 " "$3,838.40 " 65% 80% 50% 50% 65% 65% 65% 48112957 CARDIAC CATH CCL BIOSENSE BDI35DDRT EACH "$4,798.00 " 272 "$3,358.60 " "$2,399.00 " "$3,838.40 " 65% 80% 50% 50% 65% 65% 65% 48112973 CARDIAC CATH CCL BIOSENSE BDI35DFRT EACH "$4,798.00 " 272 "$3,358.60 " "$2,399.00 " "$3,838.40 " 65% 80% 50% 50% 65% 65% 65% 48112965 CARDIAC CATH CCL BIOSENSE BDI35DJRT EACH "$4,798.00 " 272 "$3,358.60 " "$2,399.00 " "$3,838.40 " 65% 80% 50% 50% 65% 65% 65% 48113005 CARDIAC CATH CCL BIOSENSE BDI35FFRT EACH "$4,798.00 " 272 "$3,358.60 " "$2,399.00 " "$3,838.40 " 65% 80% 50% 50% 65% 65% 65% 48112932 CARDIAC CATH CCL BIOSENSE BDI35FJRT EACH "$4,798.00 " 272 "$3,358.60 " "$2,399.00 " "$3,838.40 " 65% 80% 50% 50% 65% 65% 65% 48113013 CARDIAC CATH CCL BIOSENSE BDI35JJRT EACH "$4,798.00 " 272 "$3,358.60 " "$2,399.00 " "$3,838.40 " 65% 80% 50% 50% 65% 65% 65% 48112924 CARDIAC CATH CCL BIOSENSE BDI75TCDDRT EACH "$4,603.00 " 272 "$3,222.10 " "$2,301.50 " "$3,682.40 " 65% 80% 50% 50% 65% 65% 65% 48112890 CARDIAC CATH CCL BIOSENSE BDI75TCDFRT EACH "$4,603.00 " 272 "$3,222.10 " "$2,301.50 " "$3,682.40 " 65% 80% 50% 50% 65% 65% 65% 48112908 CARDIAC CATH CCL BIOSENSE BDI75TCFFRT EACH "$4,603.00 " 272 "$3,222.10 " "$2,301.50 " "$3,682.40 " 65% 80% 50% 50% 65% 65% 65% 48112916 CARDIAC CATH CCL BIOSENSE BDI75TCFJRT EACH "$4,603.00 " 272 "$3,222.10 " "$2,301.50 " "$3,682.40 " 65% 80% 50% 50% 65% 65% 65% 48112882 CARDIAC CATH CCL BIOSENSE BDI75TCJJRT EACH "$4,603.00 " 272 "$3,222.10 " "$2,301.50 " "$3,682.40 " 65% 80% 50% 50% 65% 65% 65% 48115695 CARDIAC CATH CCL BIOSENSE BN7TCDD4L EACH "$6,490.00 " 272 "$4,543.00 " "$3,245.00 " "$5,192.00 " 65% 80% 50% 50% 65% 65% 65% 48115745 CARDIAC CATH CCL BIOSENSE BN7TCDD8L EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115737 CARDIAC CATH CCL BIOSENSE BN7TCDF4L EACH "$6,490.00 " 272 "$4,543.00 " "$3,245.00 " "$5,192.00 " 65% 80% 50% 50% 65% 65% 65% 48115752 CARDIAC CATH CCL BIOSENSE BN7TCDF8L EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115703 CARDIAC CATH CCL BIOSENSE BN7TCFF4L EACH "$6,490.00 " 272 "$4,543.00 " "$3,245.00 " "$5,192.00 " 65% 80% 50% 50% 65% 65% 65% 48115760 CARDIAC CATH CCL BIOSENSE BN7TCFF8L EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115729 CARDIAC CATH CCL BIOSENSE BN7TCFJ4L EACH "$6,490.00 " 272 "$4,543.00 " "$3,245.00 " "$5,192.00 " 65% 80% 50% 50% 65% 65% 65% 48115778 CARDIAC CATH CCL BIOSENSE BN7TCFJ8L EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115711 CARDIAC CATH CCL BIOSENSE BN7TCJJ4L EACH "$6,490.00 " 272 "$4,543.00 " "$3,245.00 " "$5,192.00 " 65% 80% 50% 50% 65% 65% 65% 48115786 CARDIAC CATH CCL BIOSENSE BN7TCJJ8L EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48116198 CARDIAC CATH CCL BIOSENSE BNI35BBCT EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116107 CARDIAC CATH CCL BIOSENSE BNI35BBH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116206 CARDIAC CATH CCL BIOSENSE BNI35BDCT EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116115 CARDIAC CATH CCL BIOSENSE BNI35BDH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116214 CARDIAC CATH CCL BIOSENSE BNI35BFCT EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116123 CARDIAC CATH CCL BIOSENSE BNI35BFH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116149 CARDIAC CATH CCL BIOSENSE BNI35DDCT EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116057 CARDIAC CATH CCL BIOSENSE BNI35DDH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116180 CARDIAC CATH CCL BIOSENSE BNI35DFCT EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116099 CARDIAC CATH CCL BIOSENSE BNI35DFH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116222 CARDIAC CATH CCL BIOSENSE BNI35DJCT EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116131 CARDIAC CATH CCL BIOSENSE BNI35DJH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116156 CARDIAC CATH CCL BIOSENSE BNI35FFCT EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116065 CARDIAC CATH CCL BIOSENSE BNI35FFH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116172 CARDIAC CATH CCL BIOSENSE BNI35FJCT EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116081 CARDIAC CATH CCL BIOSENSE BNI35FJH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116164 CARDIAC CATH CCL BIOSENSE BNI35JJCT EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116073 CARDIAC CATH CCL BIOSENSE BNI35JJH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48115794 CARDIAC CATH CCL BIOSENSE BNI75TCDDH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48115836 CARDIAC CATH CCL BIOSENSE BNI75TCDFH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48115802 CARDIAC CATH CCL BIOSENSE BNI75TCFFH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48115828 CARDIAC CATH CCL BIOSENSE BNI75TCFJH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48115810 CARDIAC CATH CCL BIOSENSE BNI75TCJJH EACH "$8,113.00 " 272 "$5,679.10 " "$4,056.50 " "$6,490.40 " 65% 80% 50% 50% 65% 65% 65% 48116909 CARDIAC CATH CCL BIOSENSE C10MR10MSTKS EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48116891 CARDIAC CATH CCL BIOSENSE C10MRMSTKDTCS EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48115844 CARDIAC CATH CCL BIOSENSE C5MHDTCMHS EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115851 CARDIAC CATH CCL BIOSENSE C5MHNAVMHS EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115869 CARDIAC CATH CCL BIOSENSE C5MHREFMHS EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48116883 CARDIAC CATH CCL BIOSENSE C6MR10EPTRS EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48116875 CARDIAC CATH CCL BIOSENSE C6MR10EPTST EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48105613 CARDIAC CATH CCL BIOSENSE C6MRMST10SA EACH $723.00 272 $506.10 $361.50 $578.40 65% 80% 50% 50% 65% 65% 65% 48116826 CARDIAC CATH CCL BIOSENSE C6MRMST4SA EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48116859 CARDIAC CATH CCL BIOSENSE C6MRMST8SA EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48116867 CARDIAC CATH CCL BIOSENSE C6OMRMST10SA EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48116818 CARDIAC CATH CCL BIOSENSE C6TMRMST10SA EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48116834 CARDIAC CATH CCL BIOSENSE C6TMRMST4SA EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48116842 CARDIAC CATH CCL BIOSENSE C6YMRMST4SA EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48115877 CARDIAC CATH CCL BIOSENSE CB3410CT EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48199863 CARDIAC CATH CCL BIOSENSE CB3412CT EACH "$1,150.00 " 272 $805.00 $575.00 $920.00 65% 80% 50% 50% 65% 65% 65% 48115919 CARDIAC CATH CCL BIOSENSE CB3434CT EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48199897 CARDIAC CATH CCL BIOSENSE CFT001 EACH $258.00 272 $180.60 $129.00 $206.40 65% 80% 50% 50% 65% 65% 65% 48115455 CARDIAC CATH CCL BIOSENSE CFT003 EACH $243.00 272 $170.10 $121.50 $194.40 65% 80% 50% 50% 65% 65% 65% 48115901 CARDIAC CATH CCL BIOSENSE CG2025CT EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48199889 CARDIAC CATH CCL BIOSENSE CR3425CT EACH "$1,150.00 " 272 $805.00 $575.00 $920.00 65% 80% 50% 50% 65% 65% 65% 48199855 CARDIAC CATH CCL BIOSENSE CR3434CT EACH "$1,150.00 " 272 $805.00 $575.00 $920.00 65% 80% 50% 50% 65% 65% 65% 48112627 CARDIAC CATH CCL BIOSENSE CR7TCS4RT EACH "$3,523.00 " 272 "$2,466.10 " "$1,761.50 " "$2,818.40 " 65% 80% 50% 50% 65% 65% 65% 48112635 CARDIAC CATH CCL BIOSENSE CR7TCS4RTU EACH "$3,523.00 " 272 "$2,466.10 " "$1,761.50 " "$2,818.40 " 65% 80% 50% 50% 65% 65% 65% 48112643 CARDIAC CATH CCL BIOSENSE CR7TCSIRT EACH "$6,490.00 " 272 "$4,543.00 " "$3,245.00 " "$5,192.00 " 65% 80% 50% 50% 65% 65% 65% 48115950 CARDIAC CATH CCL BIOSENSE CY1210CT EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115935 CARDIAC CATH CCL BIOSENSE CY1212CT EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115075 CARDIAC CATH CCL BIOSENSE D1085412 EACH $523.00 272 $366.10 $261.50 $418.40 65% 80% 50% 50% 65% 65% 65% 48115083 CARDIAC CATH CCL BIOSENSE D1085413 EACH $523.00 272 $366.10 $261.50 $418.40 65% 80% 50% 50% 65% 65% 65% 48115091 CARDIAC CATH CCL BIOSENSE D1085414 EACH $580.00 272 $406.00 $290.00 $464.00 65% 80% 50% 50% 65% 65% 65% 48114987 CARDIAC CATH CCL BIOSENSE D1086784 EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114383 CARDIAC CATH CCL BIOSENSE D117136 EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48115273 CARDIAC CATH CCL BIOSENSE D128201 EACH "$5,400.00 " 272 "$3,780.00 " "$2,700.00 " "$4,320.00 " 65% 80% 50% 50% 65% 65% 65% 48115307 CARDIAC CATH CCL BIOSENSE D128202 EACH "$5,400.00 " 272 "$3,780.00 " "$2,700.00 " "$4,320.00 " 65% 80% 50% 50% 65% 65% 65% 48115315 CARDIAC CATH CCL BIOSENSE D128203 EACH "$5,400.00 " 272 "$3,780.00 " "$2,700.00 " "$4,320.00 " 65% 80% 50% 50% 65% 65% 65% 48115323 CARDIAC CATH CCL BIOSENSE D128204 EACH "$5,400.00 " 272 "$3,780.00 " "$2,700.00 " "$4,320.00 " 65% 80% 50% 50% 65% 65% 65% 48115281 CARDIAC CATH CCL BIOSENSE D128206 EACH "$5,400.00 " 272 "$3,780.00 " "$2,700.00 " "$4,320.00 " 65% 80% 50% 50% 65% 65% 65% 48115299 CARDIAC CATH CCL BIOSENSE D128207 EACH "$5,400.00 " 272 "$3,780.00 " "$2,700.00 " "$4,320.00 " 65% 80% 50% 50% 65% 65% 65% 48115349 CARDIAC CATH CCL BIOSENSE D128209 EACH "$5,400.00 " 272 "$3,780.00 " "$2,700.00 " "$4,320.00 " 65% 80% 50% 50% 65% 65% 65% 48115331 CARDIAC CATH CCL BIOSENSE D128210 EACH "$5,400.00 " 272 "$3,780.00 " "$2,700.00 " "$4,320.00 " 65% 80% 50% 50% 65% 65% 65% 48115356 CARDIAC CATH CCL BIOSENSE D128212 EACH "$5,400.00 " 272 "$3,780.00 " "$2,700.00 " "$4,320.00 " 65% 80% 50% 50% 65% 65% 65% 48115885 CARDIAC CATH CCL BIOSENSE D128622 EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115943 CARDIAC CATH CCL BIOSENSE D128623 EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115927 CARDIAC CATH CCL BIOSENSE D128624 EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115893 CARDIAC CATH CCL BIOSENSE D128627 EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115968 CARDIAC CATH CCL BIOSENSE D128709 EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115463 CARDIAC CATH CCL BIOSENSE D129704 EACH "$1,228.00 " 272 $859.60 $614.00 $982.40 65% 80% 50% 50% 65% 65% 65% 48115497 CARDIAC CATH CCL BIOSENSE D129707 EACH "$1,228.00 " 272 $859.60 $614.00 $982.40 65% 80% 50% 50% 65% 65% 65% 48199871 CARDIAC CATH CCL BIOSENSE D130302 EACH "$1,298.00 " 272 $908.60 $649.00 "$1,038.40 " 65% 80% 50% 50% 65% 65% 65% 48115471 CARDIAC CATH CCL BIOSENSE D130303 EACH "$1,228.00 " 272 $859.60 $614.00 $982.40 65% 80% 50% 50% 65% 65% 65% 48114144 CARDIAC CATH CCL BIOSENSE D131209S EACH "$3,928.00 " 272 "$2,749.60 " "$1,964.00 " "$3,142.40 " 65% 80% 50% 50% 65% 65% 65% 48115976 CARDIAC CATH CCL BIOSENSE D131501 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115984 CARDIAC CATH CCL BIOSENSE D131502 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115992 CARDIAC CATH CCL BIOSENSE D131503 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48116040 CARDIAC CATH CCL BIOSENSE D131504 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48113047 CARDIAC CATH CCL BIOSENSE D131601 EACH "$4,265.00 " 272 "$2,985.50 " "$2,132.50 " "$3,412.00 " 65% 80% 50% 50% 65% 65% 65% 48113054 CARDIAC CATH CCL BIOSENSE D131602 EACH "$4,265.00 " 272 "$2,985.50 " "$2,132.50 " "$3,412.00 " 65% 80% 50% 50% 65% 65% 65% 48113039 CARDIAC CATH CCL BIOSENSE D131603 EACH "$4,265.00 " 272 "$2,985.50 " "$2,132.50 " "$3,412.00 " 65% 80% 50% 50% 65% 65% 65% 48113021 CARDIAC CATH CCL BIOSENSE D131604 EACH "$4,265.00 " 272 "$2,985.50 " "$2,132.50 " "$3,412.00 " 65% 80% 50% 50% 65% 65% 65% 48116008 CARDIAC CATH CCL BIOSENSE D131801 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48116016 CARDIAC CATH CCL BIOSENSE D131802 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48116024 CARDIAC CATH CCL BIOSENSE D131803 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48116032 CARDIAC CATH CCL BIOSENSE D131804 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48116248 CARDIAC CATH CCL BIOSENSE D132701 EACH "$9,468.00 " 272 "$6,627.60 " "$4,734.00 " "$7,574.40 " 65% 80% 50% 50% 65% 65% 65% 48116255 CARDIAC CATH CCL BIOSENSE D132702 EACH "$9,468.00 " 272 "$6,627.60 " "$4,734.00 " "$7,574.40 " 65% 80% 50% 50% 65% 65% 65% 48116263 CARDIAC CATH CCL BIOSENSE D132703 EACH "$9,468.00 " 272 "$6,627.60 " "$4,734.00 " "$7,574.40 " 65% 80% 50% 50% 65% 65% 65% 48116271 CARDIAC CATH CCL BIOSENSE D132704 EACH "$9,468.00 " 272 "$6,627.60 " "$4,734.00 " "$7,574.40 " 65% 80% 50% 50% 65% 65% 65% 48116289 CARDIAC CATH CCL BIOSENSE D132705 EACH "$9,468.00 " 272 "$6,627.60 " "$4,734.00 " "$7,574.40 " 65% 80% 50% 50% 65% 65% 65% 48116297 CARDIAC CATH CCL BIOSENSE D133601 EACH "$8,923.00 " 272 "$6,246.10 " "$4,461.50 " "$7,138.40 " 65% 80% 50% 50% 65% 65% 65% 48116305 CARDIAC CATH CCL BIOSENSE D133602 EACH "$8,923.00 " 272 "$6,246.10 " "$4,461.50 " "$7,138.40 " 65% 80% 50% 50% 65% 65% 65% 48116313 CARDIAC CATH CCL BIOSENSE D133603 EACH "$8,923.00 " 272 "$6,246.10 " "$4,461.50 " "$7,138.40 " 65% 80% 50% 50% 65% 65% 65% 48114086 CARDIAC CATH CCL BIOSENSE D134301 EACH "$4,868.00 " 272 "$3,407.60 " "$2,434.00 " "$3,894.40 " 65% 80% 50% 50% 65% 65% 65% 48114052 CARDIAC CATH CCL BIOSENSE D134302 EACH "$4,868.00 " 272 "$3,407.60 " "$2,434.00 " "$3,894.40 " 65% 80% 50% 50% 65% 65% 65% 48199814 CARDIAC CATH CCL BIOSENSE D134401 EACH "$1,100.00 " 272 $770.00 $550.00 $880.00 65% 80% 50% 50% 65% 65% 65% 48115448 CARDIAC CATH CCL BIOSENSE D134402 EACH "$4,250.00 " 272 "$2,975.00 " "$2,125.00 " "$3,400.00 " 65% 80% 50% 50% 65% 65% 65% 48116347 CARDIAC CATH CCL BIOSENSE D134701 EACH "$9,155.00 " 272 "$6,408.50 " "$4,577.50 " "$7,324.00 " 65% 80% 50% 50% 65% 65% 65% 48116354 CARDIAC CATH CCL BIOSENSE D134702 EACH "$9,155.00 " 272 "$6,408.50 " "$4,577.50 " "$7,324.00 " 65% 80% 50% 50% 65% 65% 65% 48116362 CARDIAC CATH CCL BIOSENSE D134703 EACH "$9,155.00 " 272 "$6,408.50 " "$4,577.50 " "$7,324.00 " 65% 80% 50% 50% 65% 65% 65% 48116370 CARDIAC CATH CCL BIOSENSE D134801 EACH "$9,675.00 " 272 "$6,772.50 " "$4,837.50 " "$7,740.00 " 65% 80% 50% 50% 65% 65% 65% 48116388 CARDIAC CATH CCL BIOSENSE D134802 EACH "$9,675.00 " 272 "$6,772.50 " "$4,837.50 " "$7,740.00 " 65% 80% 50% 50% 65% 65% 65% 48116396 CARDIAC CATH CCL BIOSENSE D134803 EACH "$9,675.00 " 272 "$6,772.50 " "$4,837.50 " "$7,740.00 " 65% 80% 50% 50% 65% 65% 65% 48114151 CARDIAC CATH CCL BIOSENSE D134901 EACH "$3,928.00 " 272 "$2,749.60 " "$1,964.00 " "$3,142.40 " 65% 80% 50% 50% 65% 65% 65% 48114235 CARDIAC CATH CCL BIOSENSE D134902 EACH "$4,463.00 " 272 "$3,124.10 " "$2,231.50 " "$3,570.40 " 65% 80% 50% 50% 65% 65% 65% 48114177 CARDIAC CATH CCL BIOSENSE D134903 EACH "$3,928.00 " 272 "$2,749.60 " "$1,964.00 " "$3,142.40 " 65% 80% 50% 50% 65% 65% 65% 48114243 CARDIAC CATH CCL BIOSENSE D134904 EACH "$4,463.00 " 272 "$3,124.10 " "$2,231.50 " "$3,570.40 " 65% 80% 50% 50% 65% 65% 65% 48114219 CARDIAC CATH CCL BIOSENSE D134905 EACH "$3,928.00 " 272 "$2,749.60 " "$1,964.00 " "$3,142.40 " 65% 80% 50% 50% 65% 65% 65% 48114227 CARDIAC CATH CCL BIOSENSE D134906 EACH "$4,463.00 " 272 "$3,124.10 " "$2,231.50 " "$3,570.40 " 65% 80% 50% 50% 65% 65% 65% 48114136 CARDIAC CATH CCL BIOSENSE D134909 EACH "$3,928.00 " 272 "$2,749.60 " "$1,964.00 " "$3,142.40 " 65% 80% 50% 50% 65% 65% 65% 48113831 CARDIAC CATH CCL BIOSENSE D135303 EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113823 CARDIAC CATH CCL BIOSENSE D135304 EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113856 CARDIAC CATH CCL BIOSENSE D135305 EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113351 CARDIAC CATH CCL BIOSENSE D135501 EACH "$2,550.00 " 272 "$1,785.00 " "$1,275.00 " "$2,040.00 " 65% 80% 50% 50% 65% 65% 65% 48113344 CARDIAC CATH CCL BIOSENSE D135502 EACH "$2,550.00 " 272 "$1,785.00 " "$1,275.00 " "$2,040.00 " 65% 80% 50% 50% 65% 65% 65% 48113336 CARDIAC CATH CCL BIOSENSE D135901 EACH "$2,550.00 " 272 "$1,785.00 " "$1,275.00 " "$2,040.00 " 65% 80% 50% 50% 65% 65% 65% 48116800 CARDIAC CATH CCL BIOSENSE D138501 EACH "$2,825.00 " 272 "$1,977.50 " "$1,412.50 " "$2,260.00 " 65% 80% 50% 50% 65% 65% 65% 48116792 CARDIAC CATH CCL BIOSENSE D138503 EACH "$2,825.00 " 272 "$1,977.50 " "$1,412.50 " "$2,260.00 " 65% 80% 50% 50% 65% 65% 65% 48114409 CARDIAC CATH CCL BIOSENSE D139801 EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48116784 CARDIAC CATH CCL BIOSENSE D140010 EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48116776 CARDIAC CATH CCL BIOSENSE D140011 EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48115414 CARDIAC CATH CCL BIOSENSE D160901 EACH "$7,975.00 " 272 "$5,582.50 " "$3,987.50 " "$6,380.00 " 65% 80% 50% 50% 65% 65% 65% 48115422 CARDIAC CATH CCL BIOSENSE D160902 EACH "$7,975.00 " 272 "$5,582.50 " "$3,987.50 " "$6,380.00 " 65% 80% 50% 50% 65% 65% 65% 48115430 CARDIAC CATH CCL BIOSENSE D160903 EACH "$7,975.00 " 272 "$5,582.50 " "$3,987.50 " "$6,380.00 " 65% 80% 50% 50% 65% 65% 65% 48115380 CARDIAC CATH CCL BIOSENSE D160904 EACH "$7,975.00 " 272 "$5,582.50 " "$3,987.50 " "$6,380.00 " 65% 80% 50% 50% 65% 65% 65% 48115398 CARDIAC CATH CCL BIOSENSE D160905 EACH "$7,975.00 " 272 "$5,582.50 " "$3,987.50 " "$6,380.00 " 65% 80% 50% 50% 65% 65% 65% 48115406 CARDIAC CATH CCL BIOSENSE D160906 EACH "$7,975.00 " 272 "$5,582.50 " "$3,987.50 " "$6,380.00 " 65% 80% 50% 50% 65% 65% 65% 48113443 CARDIAC CATH CCL BIOSENSE D4S04DR005RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113450 CARDIAC CATH CCL BIOSENSE D4S04FR005RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113674 CARDIAC CATH CCL BIOSENSE D4S10PR282RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113732 CARDIAC CATH CCL BIOSENSE D505AR005RT EACH "$1,020.00 " 272 $714.00 $510.00 $816.00 65% 80% 50% 50% 65% 65% 65% 48113708 CARDIAC CATH CCL BIOSENSE D505FR005RT EACH "$1,020.00 " 272 $714.00 $510.00 $816.00 65% 80% 50% 50% 65% 65% 65% 48113898 CARDIAC CATH CCL BIOSENSE D508D005RT EACH "$1,903.00 " 272 "$1,332.10 " $951.50 "$1,522.40 " 65% 80% 50% 50% 65% 65% 65% 48113492 CARDIAC CATH CCL BIOSENSE D508DP10RT EACH "$1,343.00 " 272 $940.10 $671.50 "$1,074.40 " 65% 80% 50% 50% 65% 65% 65% 48113583 CARDIAC CATH CCL BIOSENSE D510DRP10RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113658 CARDIAC CATH CCL BIOSENSE D510F2250RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113641 CARDIAC CATH CCL BIOSENSE D510P2R5155RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113633 CARDIAC CATH CCL BIOSENSE D510PR005RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113260 CARDIAC CATH CCL BIOSENSE D5S06AL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113625 CARDIAC CATH CCL BIOSENSE D5S10MZR282RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113617 CARDIAC CATH CCL BIOSENSE D5S10PR005RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113252 CARDIAC CATH CCL BIOSENSE D5SAL252RT EACH "$1,218.00 " 272 $852.60 $609.00 $974.40 65% 80% 50% 50% 65% 65% 65% 48113476 CARDIAC CATH CCL BIOSENSE D606DR002RT EACH "$1,218.00 " 272 $852.60 $609.00 $974.40 65% 80% 50% 50% 65% 65% 65% 48113864 CARDIAC CATH CCL BIOSENSE D608DR002CT EACH "$1,343.00 " 272 $940.10 $671.50 "$1,074.40 " 65% 80% 50% 50% 65% 65% 65% 48113500 CARDIAC CATH CCL BIOSENSE D608DR002RT EACH "$1,343.00 " 272 $940.10 $671.50 "$1,074.40 " 65% 80% 50% 50% 65% 65% 65% 48113484 CARDIAC CATH CCL BIOSENSE D608DR252RT EACH "$1,343.00 " 272 $940.10 $671.50 "$1,074.40 " 65% 80% 50% 50% 65% 65% 65% 48113591 CARDIAC CATH CCL BIOSENSE D610DR002RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113559 CARDIAC CATH CCL BIOSENSE D610DR005RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113567 CARDIAC CATH CCL BIOSENSE D610DR252RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113849 CARDIAC CATH CCL BIOSENSE D610DRP10CT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113526 CARDIAC CATH CCL BIOSENSE D610DRP10RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113542 CARDIAC CATH CCL BIOSENSE D610FR005RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113534 CARDIAC CATH CCL BIOSENSE D610FR252RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113575 CARDIAC CATH CCL BIOSENSE D6A10DRP10RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113179 CARDIAC CATH CCL BIOSENSE D6BL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113245 CARDIAC CATH CCL BIOSENSE D6DL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113799 CARDIAC CATH CCL BIOSENSE D6DR005CT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113377 CARDIAC CATH CCL BIOSENSE D6DR005RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113385 CARDIAC CATH CCL BIOSENSE D6DR010RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113807 CARDIAC CATH CCL BIOSENSE D6DR252CT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113369 CARDIAC CATH CCL BIOSENSE D6DR252RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113401 CARDIAC CATH CCL BIOSENSE D6FR252RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48114334 CARDIAC CATH CCL BIOSENSE D6R20P12RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48113682 CARDIAC CATH CCL BIOSENSE D6S08DRPRYRT EACH "$1,903.00 " 272 "$1,332.10 " $951.50 "$1,522.40 " 65% 80% 50% 50% 65% 65% 65% 48113393 CARDIAC CATH CCL BIOSENSE D6S270L252RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48114300 CARDIAC CATH CCL BIOSENSE D6T20282RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48199848 CARDIAC CATH CCL BIOSENSE D6T2028RT EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48112312 CARDIAC CATH CCL BIOSENSE D6TAL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112353 CARDIAC CATH CCL BIOSENSE D6TBL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112551 CARDIAC CATH CCL BIOSENSE D6TCAL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112528 CARDIAC CATH CCL BIOSENSE D6TCBL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113310 CARDIAC CATH CCL BIOSENSE D6TCCL252RT EACH "$2,965.00 " 272 "$2,075.50 " "$1,482.50 " "$2,372.00 " 65% 80% 50% 50% 65% 65% 65% 48112502 CARDIAC CATH CCL BIOSENSE D6TCDL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112593 CARDIAC CATH CCL BIOSENSE D6TCEL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112320 CARDIAC CATH CCL BIOSENSE D6TDL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113468 CARDIAC CATH CCL BIOSENSE D706DR002RT EACH "$1,218.00 " 272 $852.60 $609.00 $974.40 65% 80% 50% 50% 65% 65% 65% 48113278 CARDIAC CATH CCL BIOSENSE D708DL002RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113518 CARDIAC CATH CCL BIOSENSE D708DR002RT EACH "$1,343.00 " 272 $940.10 $671.50 "$1,074.40 " 65% 80% 50% 50% 65% 65% 65% 48113690 CARDIAC CATH CCL BIOSENSE D708RHISRT EACH "$1,903.00 " 272 "$1,332.10 " $951.50 "$1,522.40 " 65% 80% 50% 50% 65% 65% 65% 48113815 CARDIAC CATH CCL BIOSENSE D710DRP10CT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48113666 CARDIAC CATH CCL BIOSENSE D710DRP10RT EACH "$1,425.00 " 272 $997.50 $712.50 "$1,140.00 " 65% 80% 50% 50% 65% 65% 65% 48114391 CARDIAC CATH CCL BIOSENSE D728260RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114342 CARDIAC CATH CCL BIOSENSE D7A20131RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48113229 CARDIAC CATH CCL BIOSENSE D7AL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113187 CARDIAC CATH CCL BIOSENSE D7BL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112155 CARDIAC CATH CCL BIOSENSE D7BTBL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112429 CARDIAC CATH CCL BIOSENSE D7BTCBL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113302 CARDIAC CATH CCL BIOSENSE D7BTCCL252RT EACH "$2,965.00 " 272 "$2,075.50 " "$1,482.50 " "$2,372.00 " 65% 80% 50% 50% 65% 65% 65% 48112411 CARDIAC CATH CCL BIOSENSE D7BTCD5L252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112387 CARDIAC CATH CCL BIOSENSE D7BTCDL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112460 CARDIAC CATH CCL BIOSENSE D7BTCEL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112395 CARDIAC CATH CCL BIOSENSE D7BTCF5L252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112437 CARDIAC CATH CCL BIOSENSE D7BTCFL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112734 CARDIAC CATH CCL BIOSENSE D7BTCJ5L EACH "$2,965.00 " 272 "$2,075.50 " "$1,482.50 " "$2,372.00 " 65% 80% 50% 50% 65% 65% 65% 48112692 CARDIAC CATH CCL BIOSENSE D7BTCJL EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112189 CARDIAC CATH CCL BIOSENSE D7BTCL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112270 CARDIAC CATH CCL BIOSENSE D7BTD5L252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112205 CARDIAC CATH CCL BIOSENSE D7BTDL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112254 CARDIAC CATH CCL BIOSENSE D7BTEL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112247 CARDIAC CATH CCL BIOSENSE D7BTF5L252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112262 CARDIAC CATH CCL BIOSENSE D7BTFL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112684 CARDIAC CATH CCL BIOSENSE D7BTG5L EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112676 CARDIAC CATH CCL BIOSENSE D7BTGL EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112650 CARDIAC CATH CCL BIOSENSE D7BTJ5L EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112668 CARDIAC CATH CCL BIOSENSE D7BTJL EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113161 CARDIAC CATH CCL BIOSENSE D7CL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113195 CARDIAC CATH CCL BIOSENSE D7DL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113427 CARDIAC CATH CCL BIOSENSE D7DR005RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113435 CARDIAC CATH CCL BIOSENSE D7DR010RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113781 CARDIAC CATH CCL BIOSENSE D7DR252CT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113419 CARDIAC CATH CCL BIOSENSE D7DR252RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113211 CARDIAC CATH CCL BIOSENSE D7EL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113237 CARDIAC CATH CCL BIOSENSE D7FL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113872 CARDIAC CATH CCL BIOSENSE D7FR252RT EACH $938.00 272 $656.60 $469.00 $750.40 65% 80% 50% 50% 65% 65% 65% 48113906 CARDIAC CATH CCL BIOSENSE D7L1012RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114094 CARDIAC CATH CCL BIOSENSE D7L1015CT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48113955 CARDIAC CATH CCL BIOSENSE D7L1015RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114102 CARDIAC CATH CCL BIOSENSE D7L1020CT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48113930 CARDIAC CATH CCL BIOSENSE D7L1020RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114029 CARDIAC CATH CCL BIOSENSE D7L102515RT EACH "$4,868.00 " 272 "$3,407.60 " "$2,434.00 " "$3,894.40 " 65% 80% 50% 50% 65% 65% 65% 48113914 CARDIAC CATH CCL BIOSENSE D7L1025RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48113922 CARDIAC CATH CCL BIOSENSE D7L1030RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114128 CARDIAC CATH CCL BIOSENSE D7L2015CT EACH "$3,790.00 " 272 "$2,653.00 " "$1,895.00 " "$3,032.00 " 65% 80% 50% 50% 65% 65% 65% 48113989 CARDIAC CATH CCL BIOSENSE D7L2015RT EACH "$3,790.00 " 272 "$2,653.00 " "$1,895.00 " "$3,032.00 " 65% 80% 50% 50% 65% 65% 65% 48114110 CARDIAC CATH CCL BIOSENSE D7L2020CT EACH "$3,790.00 " 272 "$2,653.00 " "$1,895.00 " "$3,032.00 " 65% 80% 50% 50% 65% 65% 65% 48113963 CARDIAC CATH CCL BIOSENSE D7L2020RT EACH "$3,790.00 " 272 "$2,653.00 " "$1,895.00 " "$3,032.00 " 65% 80% 50% 50% 65% 65% 65% 48114037 CARDIAC CATH CCL BIOSENSE D7L202515RT EACH "$4,868.00 " 272 "$3,407.60 " "$2,434.00 " "$3,894.40 " 65% 80% 50% 50% 65% 65% 65% 48114003 CARDIAC CATH CCL BIOSENSE D7L2025RT EACH "$3,790.00 " 272 "$2,653.00 " "$1,895.00 " "$3,032.00 " 65% 80% 50% 50% 65% 65% 65% 48113971 CARDIAC CATH CCL BIOSENSE D7L2030RT EACH "$3,790.00 " 272 "$2,653.00 " "$1,895.00 " "$3,032.00 " 65% 80% 50% 50% 65% 65% 65% 48114326 CARDIAC CATH CCL BIOSENSE D7R20LCSRT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114367 CARDIAC CATH CCL BIOSENSE D7R20P14CT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114359 CARDIAC CATH CCL BIOSENSE D7R20P14RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114375 CARDIAC CATH CCL BIOSENSE D7T20282CT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114284 CARDIAC CATH CCL BIOSENSE D7T20282RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48114292 CARDIAC CATH CCL BIOSENSE D7T20P15RT EACH "$3,245.00 " 272 "$2,271.50 " "$1,622.50 " "$2,596.00 " 65% 80% 50% 50% 65% 65% 65% 48113294 CARDIAC CATH CCL BIOSENSE D7T270L252RT EACH "$2,965.00 " 272 "$2,075.50 " "$1,482.50 " "$2,372.00 " 65% 80% 50% 50% 65% 65% 65% 48112346 CARDIAC CATH CCL BIOSENSE D7TAL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112296 CARDIAC CATH CCL BIOSENSE D7TBL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112569 CARDIAC CATH CCL BIOSENSE D7TC270L252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112478 CARDIAC CATH CCL BIOSENSE D7TCAL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113088 CARDIAC CATH CCL BIOSENSE D7TCB8L162RT EACH "$3,373.00 " 272 "$2,361.10 " "$1,686.50 " "$2,698.40 " 65% 80% 50% 50% 65% 65% 65% 48112601 CARDIAC CATH CCL BIOSENSE D7TCBG252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112486 CARDIAC CATH CCL BIOSENSE D7TCBL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112544 CARDIAC CATH CCL BIOSENSE D7TCCG252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112536 CARDIAC CATH CCL BIOSENSE D7TCCL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113096 CARDIAC CATH CCL BIOSENSE D7TCD8L162RT EACH "$3,373.00 " 272 "$2,361.10 " "$1,686.50 " "$2,698.40 " 65% 80% 50% 50% 65% 65% 65% 48112510 CARDIAC CATH CCL BIOSENSE D7TCDG252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112619 CARDIAC CATH CCL BIOSENSE D7TCDL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113104 CARDIAC CATH CCL BIOSENSE D7TCE8L162RT EACH "$3,928.00 " 272 "$2,749.60 " "$1,964.00 " "$3,142.40 " 65% 80% 50% 50% 65% 65% 65% 48112585 CARDIAC CATH CCL BIOSENSE D7TCEL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113062 CARDIAC CATH CCL BIOSENSE D7TCF8L162RT EACH "$3,373.00 " 272 "$2,361.10 " "$1,686.50 " "$2,698.40 " 65% 80% 50% 50% 65% 65% 65% 48113328 CARDIAC CATH CCL BIOSENSE D7TCFG252RT EACH "$2,965.00 " 272 "$2,075.50 " "$1,482.50 " "$2,372.00 " 65% 80% 50% 50% 65% 65% 65% 48112577 CARDIAC CATH CCL BIOSENSE D7TCFL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113070 CARDIAC CATH CCL BIOSENSE D7TCJ8L162RT EACH "$3,373.00 " 272 "$2,361.10 " "$1,686.50 " "$2,698.40 " 65% 80% 50% 50% 65% 65% 65% 48112338 CARDIAC CATH CCL BIOSENSE D7TCL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112494 CARDIAC CATH CCL BIOSENSE D7TCPSL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112361 CARDIAC CATH CCL BIOSENSE D7TDL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112304 CARDIAC CATH CCL BIOSENSE D7TEL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112288 CARDIAC CATH CCL BIOSENSE D7TFL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113120 CARDIAC CATH CCL BIOSENSE D8BRCG252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113138 CARDIAC CATH CCL BIOSENSE D8BRDL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48113112 CARDIAC CATH CCL BIOSENSE D8BRFL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112163 CARDIAC CATH CCL BIOSENSE D8BTBL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112403 CARDIAC CATH CCL BIOSENSE D8BTCBL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112379 CARDIAC CATH CCL BIOSENSE D8BTCDL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112445 CARDIAC CATH CCL BIOSENSE D8BTCEL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112452 CARDIAC CATH CCL BIOSENSE D8BTCFL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112700 CARDIAC CATH CCL BIOSENSE D8BTCG5L EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112718 CARDIAC CATH CCL BIOSENSE D8BTCGL EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112197 CARDIAC CATH CCL BIOSENSE D8BTD5L252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112213 CARDIAC CATH CCL BIOSENSE D8BTDL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112221 CARDIAC CATH CCL BIOSENSE D8BTF5L252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112239 CARDIAC CATH CCL BIOSENSE D8BTFL252RT EACH "$2,308.00 " 272 "$1,615.60 " "$1,154.00 " "$1,846.40 " 65% 80% 50% 50% 65% 65% 65% 48112726 CARDIAC CATH CCL BIOSENSE D8BTG5L EACH "$2,965.00 " 272 "$2,075.50 " "$1,482.50 " "$2,372.00 " 65% 80% 50% 50% 65% 65% 65% 48113286 CARDIAC CATH CCL BIOSENSE D8BTGL EACH "$2,965.00 " 272 "$2,075.50 " "$1,482.50 " "$2,372.00 " 65% 80% 50% 50% 65% 65% 65% 48116941 CARDIAC CATH CCL BIOSENSE DI7TCBLRT EACH "$4,058.00 " 272 "$2,840.60 " "$2,029.00 " "$3,246.40 " 65% 80% 50% 50% 65% 65% 65% 48116917 CARDIAC CATH CCL BIOSENSE DI7TCDLRT EACH "$4,058.00 " 272 "$2,840.60 " "$2,029.00 " "$3,246.40 " 65% 80% 50% 50% 65% 65% 65% 48116925 CARDIAC CATH CCL BIOSENSE DI7TCFLRT EACH "$4,058.00 " 272 "$2,840.60 " "$2,029.00 " "$3,246.40 " 65% 80% 50% 50% 65% 65% 65% 48116933 CARDIAC CATH CCL BIOSENSE DI7TCJLRT EACH "$4,058.00 " 272 "$2,840.60 " "$2,029.00 " "$3,246.40 " 65% 80% 50% 50% 65% 65% 65% 48114169 CARDIAC CATH CCL BIOSENSE DLN1215CT EACH "$3,928.00 " 272 "$2,749.60 " "$1,964.00 " "$3,142.40 " 65% 80% 50% 50% 65% 65% 65% 48114185 CARDIAC CATH CCL BIOSENSE DLN1220CT EACH "$3,928.00 " 272 "$2,749.60 " "$1,964.00 " "$3,142.40 " 65% 80% 50% 50% 65% 65% 65% 48114193 CARDIAC CATH CCL BIOSENSE DLN1225CT EACH "$3,928.00 " 272 "$2,749.60 " "$1,964.00 " "$3,142.40 " 65% 80% 50% 50% 65% 65% 65% 48114250 CARDIAC CATH CCL BIOSENSE DLN2215CT EACH "$4,463.00 " 272 "$3,124.10 " "$2,231.50 " "$3,570.40 " 65% 80% 50% 50% 65% 65% 65% 48114268 CARDIAC CATH CCL BIOSENSE DLN2220CT EACH "$4,463.00 " 272 "$3,124.10 " "$2,231.50 " "$3,570.40 " 65% 80% 50% 50% 65% 65% 65% 48114276 CARDIAC CATH CCL BIOSENSE DLN2225CT EACH "$4,463.00 " 272 "$3,124.10 " "$2,231.50 " "$3,570.40 " 65% 80% 50% 50% 65% 65% 65% 48114821 CARDIAC CATH CCL BIOSENSE F4QA005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115166 CARDIAC CATH CCL BIOSENSE F4QD005RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114813 CARDIAC CATH CCL BIOSENSE F4QF005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114805 CARDIAC CATH CCL BIOSENSE F4QH005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115117 CARDIAC CATH CCL BIOSENSE F4SHH252RT EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48115158 CARDIAC CATH CCL BIOSENSE F5ADP282CT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48115026 CARDIAC CATH CCL BIOSENSE F5ADP282RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48115000 CARDIAC CATH CCL BIOSENSE F5ADPP10RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114524 CARDIAC CATH CCL BIOSENSE F5CQA005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114532 CARDIAC CATH CCL BIOSENSE F5CQA252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114631 CARDIAC CATH CCL BIOSENSE F5CQD005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115224 CARDIAC CATH CCL BIOSENSE F5CQD252RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114516 CARDIAC CATH CCL BIOSENSE F5CQF005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48199822 CARDIAC CATH CCL BIOSENSE F5CQF252RT EACH $903.00 272 $632.10 $451.50 $722.40 65% 80% 50% 50% 65% 65% 65% 48114540 CARDIAC CATH CCL BIOSENSE F5QA002RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114565 CARDIAC CATH CCL BIOSENSE F5QA005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114557 CARDIAC CATH CCL BIOSENSE F5QA252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48199830 CARDIAC CATH CCL BIOSENSE F5QAOO5CF EACH $355.00 272 $248.50 $177.50 $284.00 65% 80% 50% 50% 65% 65% 65% 48114581 CARDIAC CATH CCL BIOSENSE F5QD005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114599 CARDIAC CATH CCL BIOSENSE F5QD010RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114573 CARDIAC CATH CCL BIOSENSE F5QD252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115125 CARDIAC CATH CCL BIOSENSE F5QF005CT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114607 CARDIAC CATH CCL BIOSENSE F5QF005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114615 CARDIAC CATH CCL BIOSENSE F5QF010RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114623 CARDIAC CATH CCL BIOSENSE F5QL005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114797 CARDIAC CATH CCL BIOSENSE F5QL010ST EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114474 CARDIAC CATH CCL BIOSENSE F5QRA005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114490 CARDIAC CATH CCL BIOSENSE F5QRA252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114482 CARDIAC CATH CCL BIOSENSE F5QRF005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114508 CARDIAC CATH CCL BIOSENSE F5QRF252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115174 CARDIAC CATH CCL BIOSENSE F5SQA252RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114839 CARDIAC CATH CCL BIOSENSE F65QA005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114979 CARDIAC CATH CCL BIOSENSE F6ADP282RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114847 CARDIAC CATH CCL BIOSENSE F6CQA005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114862 CARDIAC CATH CCL BIOSENSE F6CQF005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114870 CARDIAC CATH CCL BIOSENSE F6CQF010RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114854 CARDIAC CATH CCL BIOSENSE F6CQF252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115018 CARDIAC CATH CCL BIOSENSE F6DF252RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114995 CARDIAC CATH CCL BIOSENSE F6DG252RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114904 CARDIAC CATH CCL BIOSENSE F6HA002RT EACH $533.00 272 $373.10 $266.50 $426.40 65% 80% 50% 50% 65% 65% 65% 48114888 CARDIAC CATH CCL BIOSENSE F6HF002RT EACH $533.00 272 $373.10 $266.50 $426.40 65% 80% 50% 50% 65% 65% 65% 48114920 CARDIAC CATH CCL BIOSENSE F6HF005RT EACH $533.00 272 $373.10 $266.50 $426.40 65% 80% 50% 50% 65% 65% 65% 48114896 CARDIAC CATH CCL BIOSENSE F6HF010RT EACH $533.00 272 $373.10 $266.50 $426.40 65% 80% 50% 50% 65% 65% 65% 48114946 CARDIAC CATH CCL BIOSENSE F6OA002RT EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48114953 CARDIAC CATH CCL BIOSENSE F6OF002RT EACH $685.00 272 $479.50 $342.50 $548.00 65% 80% 50% 50% 65% 65% 65% 48114656 CARDIAC CATH CCL BIOSENSE F6QA002RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115133 CARDIAC CATH CCL BIOSENSE F6QA005CT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114672 CARDIAC CATH CCL BIOSENSE F6QA005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114680 CARDIAC CATH CCL BIOSENSE F6QA010RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114664 CARDIAC CATH CCL BIOSENSE F6QA252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114698 CARDIAC CATH CCL BIOSENSE F6QD002RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114714 CARDIAC CATH CCL BIOSENSE F6QD005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114722 CARDIAC CATH CCL BIOSENSE F6QD010RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114706 CARDIAC CATH CCL BIOSENSE F6QD252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114730 CARDIAC CATH CCL BIOSENSE F6QF002RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115141 CARDIAC CATH CCL BIOSENSE F6QF005CT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114755 CARDIAC CATH CCL BIOSENSE F6QF005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114763 CARDIAC CATH CCL BIOSENSE F6QF010RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114649 CARDIAC CATH CCL BIOSENSE F6QF010ST EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114748 CARDIAC CATH CCL BIOSENSE F6QF252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115232 CARDIAC CATH CCL BIOSENSE F6QG010RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114771 CARDIAC CATH CCL BIOSENSE F6QK002RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114789 CARDIAC CATH CCL BIOSENSE F6QL005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115216 CARDIAC CATH CCL BIOSENSE F6QL010RT EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48115208 CARDIAC CATH CCL BIOSENSE F6QL010ST EACH $813.00 272 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% 65% 65% 48114417 CARDIAC CATH CCL BIOSENSE F6QRA005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114466 CARDIAC CATH CCL BIOSENSE F6QRA010RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114433 CARDIAC CATH CCL BIOSENSE F6QRA252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114425 CARDIAC CATH CCL BIOSENSE F6QRF005RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114458 CARDIAC CATH CCL BIOSENSE F6QRF010RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48114441 CARDIAC CATH CCL BIOSENSE F6QRF252RT EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48115067 CARDIAC CATH CCL BIOSENSE F7LADPP10RT EACH "$1,218.00 " 272 $852.60 $609.00 $974.40 65% 80% 50% 50% 65% 65% 65% 48115059 CARDIAC CATH CCL BIOSENSE F7LDG005RT EACH "$1,218.00 " 272 $852.60 $609.00 $974.40 65% 80% 50% 50% 65% 65% 65% 48115042 CARDIAC CATH CCL BIOSENSE F7LDG252RT EACH "$1,218.00 " 272 $852.60 $609.00 $974.40 65% 80% 50% 50% 65% 65% 65% 48116958 CARDIAC CATH CCL BIOSENSE F8ENNNNHSB EACH "$1,218.00 " 272 $852.60 $609.00 $974.40 65% 80% 50% 50% 65% 65% 65% 48116628 CARDIAC CATH CCL BIOSENSE FCL20100 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116636 CARDIAC CATH CCL BIOSENSE FCL20101 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116644 CARDIAC CATH CCL BIOSENSE FCL20102 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116685 CARDIAC CATH CCL BIOSENSE FCL20103 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116750 CARDIAC CATH CCL BIOSENSE FND01900 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116727 CARDIAC CATH CCL BIOSENSE FND01901 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116719 CARDIAC CATH CCL BIOSENSE FND01902 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116735 CARDIAC CATH CCL BIOSENSE FND01903 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116743 CARDIAC CATH CCL BIOSENSE FND01905 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48116768 CARDIAC CATH CCL BIOSENSE FND01906 EACH $475.00 272 $332.50 $237.50 $380.00 65% 80% 50% 50% 65% 65% 65% 48114060 CARDIAC CATH CCL BIOSENSE LN122515CT EACH "$4,868.00 " 272 "$3,407.60 " "$2,434.00 " "$3,894.40 " 65% 80% 50% 50% 65% 65% 65% 48114078 CARDIAC CATH CCL BIOSENSE LN222515CT EACH "$4,868.00 " 272 "$3,407.60 " "$2,434.00 " "$3,894.40 " 65% 80% 50% 50% 65% 65% 65% 48115489 CARDIAC CATH CCL BIOSENSE M4900633 EACH "$1,228.00 " 272 $859.60 $614.00 $982.40 65% 80% 50% 50% 65% 65% 65% 48115588 CARDIAC CATH CCL BIOSENSE NI75TCBH EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115596 CARDIAC CATH CCL BIOSENSE NI75TCCH EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115604 CARDIAC CATH CCL BIOSENSE NI75TCDH EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115612 CARDIAC CATH CCL BIOSENSE NI75TCFH EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115620 CARDIAC CATH CCL BIOSENSE NI75TCJH EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48115562 CARDIAC CATH CCL BIOSENSE NR7TCS4Y EACH "$7,033.00 " 272 "$4,923.10 " "$3,516.50 " "$5,626.40 " 65% 80% 50% 50% 65% 65% 65% 48115570 CARDIAC CATH CCL BIOSENSE NR7TCS4YU EACH "$7,033.00 " 272 "$4,923.10 " "$3,516.50 " "$5,626.40 " 65% 80% 50% 50% 65% 65% 65% 48115638 CARDIAC CATH CCL BIOSENSE NR7TCSIY EACH "$8,378.00 " 272 "$5,864.60 " "$4,189.00 " "$6,702.40 " 65% 80% 50% 50% 65% 65% 65% 48115661 CARDIAC CATH CCL BIOSENSE NS7TCB8L174HS EACH "$7,033.00 " 272 "$4,923.10 " "$3,516.50 " "$5,626.40 " 65% 80% 50% 50% 65% 65% 65% 48115505 CARDIAC CATH CCL BIOSENSE NS7TCBL174HS EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48115646 CARDIAC CATH CCL BIOSENSE NS7TCC8L174HS EACH "$7,033.00 " 272 "$4,923.10 " "$3,516.50 " "$5,626.40 " 65% 80% 50% 50% 65% 65% 65% 48115513 CARDIAC CATH CCL BIOSENSE NS7TCCL174HS EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48115679 CARDIAC CATH CCL BIOSENSE NS7TCD8L174HS EACH "$7,033.00 " 272 "$4,923.10 " "$3,516.50 " "$5,626.40 " 65% 80% 50% 50% 65% 65% 65% 48115521 CARDIAC CATH CCL BIOSENSE NS7TCDL174HS EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48115554 CARDIAC CATH CCL BIOSENSE NS7TCDM174HS EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48115539 CARDIAC CATH CCL BIOSENSE NS7TCEL174HS EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48115687 CARDIAC CATH CCL BIOSENSE NS7TCF8L174HS EACH "$7,033.00 " 272 "$4,923.10 " "$3,516.50 " "$5,626.40 " 65% 80% 50% 50% 65% 65% 65% 48115653 CARDIAC CATH CCL BIOSENSE NS7TCJ8L174HS EACH "$7,033.00 " 272 "$4,923.10 " "$3,516.50 " "$5,626.40 " 65% 80% 50% 50% 65% 65% 65% 48115547 CARDIAC CATH CCL BIOSENSE NS7TCJL174HS EACH "$5,955.00 " 272 "$4,168.50 " "$2,977.50 " "$4,764.00 " 65% 80% 50% 50% 65% 65% 65% 48113757 CARDIAC CATH CCL BIOSENSE OD73X4D010FS EACH "$2,435.00 " 272 "$1,704.50 " "$1,217.50 " "$1,948.00 " 65% 80% 50% 50% 65% 65% 65% 48113740 CARDIAC CATH CCL BIOSENSE OD78X2D005FS EACH "$2,435.00 " 272 "$1,704.50 " "$1,217.50 " "$1,948.00 " 65% 80% 50% 50% 65% 65% 65% 48115109 CARDIAC CATH CCL BIOSENSE OF63X4C010FS EACH "$1,750.00 " 272 "$1,225.00 " $875.00 "$1,400.00 " 65% 80% 50% 50% 65% 65% 65% 48116537 CARDIAC CATH CCL BIOSENSE R08255790 EACH "$4,278.00 " 272 "$2,994.60 " "$2,139.00 " "$3,422.40 " 65% 80% 50% 50% 65% 65% 65% 48116511 CARDIAC CATH CCL BIOSENSE R10043342 EACH "$4,278.00 " 272 "$2,994.60 " "$2,139.00 " "$3,422.40 " 65% 80% 50% 50% 65% 65% 65% 48116503 CARDIAC CATH CCL BIOSENSE R10135910 EACH "$4,278.00 " 272 "$2,994.60 " "$2,139.00 " "$3,422.40 " 65% 80% 50% 50% 65% 65% 65% 48116529 CARDIAC CATH CCL BIOSENSE R10135936 EACH "$4,278.00 " 272 "$2,994.60 " "$2,139.00 " "$3,422.40 " 65% 80% 50% 50% 65% 65% 65% 48116560 CARDIAC CATH CCL BIOSENSE R10438577 EACH "$4,278.00 " 272 "$2,994.60 " "$2,139.00 " "$3,422.40 " 65% 80% 50% 50% 65% 65% 65% 48116610 CARDIAC CATH CCL BIOSENSE R10439011 EACH "$6,100.00 " 272 "$4,270.00 " "$3,050.00 " "$4,880.00 " 65% 80% 50% 50% 65% 65% 65% 48116578 CARDIAC CATH CCL BIOSENSE R10439072 EACH "$4,278.00 " 272 "$2,994.60 " "$2,139.00 " "$3,422.40 " 65% 80% 50% 50% 65% 65% 65% 48116602 CARDIAC CATH CCL BIOSENSE R10439236 EACH "$6,100.00 " 272 "$4,270.00 " "$3,050.00 " "$4,880.00 " 65% 80% 50% 50% 65% 65% 65% 48115364 CARDIAC CATH CCL BIOSENSE R7D282CT EACH "$3,118.00 " 272 "$2,182.60 " "$1,559.00 " "$2,494.40 " 65% 80% 50% 50% 65% 65% 65% 48115372 CARDIAC CATH CCL BIOSENSE R7F282CT EACH "$3,118.00 " 272 "$2,182.60 " "$1,559.00 " "$2,494.40 " 65% 80% 50% 50% 65% 65% 65% 48199806 CARDIAC CATH CCL BIOSENSE SAT001 EACH $243.00 272 $170.10 $121.50 $194.40 65% 80% 50% 50% 65% 65% 65% 48116339 CARDIAC CATH CCL BIOSENSE XRP6H EACH "$1,250.00 " 272 $875.00 $625.00 "$1,000.00 " 65% 80% 50% 50% 65% 65% 65% 48116321 CARDIAC CATH CCL BIOSENSE XRPP8Y EACH "$1,250.00 " 272 $875.00 $625.00 "$1,000.00 " 65% 80% 50% 50% 65% 65% 65% 48117006 CARDIAC CATH CCL BIOSENSE-WEBSTER 10439236 EACH "$7,568.00 " 272 "$5,297.60 " "$3,784.00 " "$6,054.40 " 65% 80% 50% 50% 65% 65% 65% 48117386 CARDIAC CATH CCL BIOSENSE-WEBSTER 34A35M EACH "$3,118.00 " 272 "$2,182.60 " "$1,559.00 " "$2,494.40 " 65% 80% 50% 50% 65% 65% 65% 48117394 CARDIAC CATH CCL BIOSENSE-WEBSTER 36D35R EACH "$1,623.00 " 272 "$1,136.10 " $811.50 "$1,298.40 " 65% 80% 50% 50% 65% 65% 65% 48117493 CARDIAC CATH CCL BIOSENSE-WEBSTER CB3434CT EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48117501 CARDIAC CATH CCL BIOSENSE-WEBSTER CY1210CT EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48117519 CARDIAC CATH CCL BIOSENSE-WEBSTER CY1212CT EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48117527 CARDIAC CATH CCL BIOSENSE-WEBSTER D128624 EACH "$1,090.00 " 272 $763.00 $545.00 $872.00 65% 80% 50% 50% 65% 65% 65% 48117691 CARDIAC CATH CCL BOSTON SC H74939171080410 EACH $480.00 272 $336.00 $240.00 $384.00 65% 80% 50% 50% 65% 65% 65% 48117709 CARDIAC CATH CCL BOSTON SC H74939171120870 EACH $480.00 272 $336.00 $240.00 $384.00 65% 80% 50% 50% 65% 65% 65% 48117717 CARDIAC CATH CCL BOSTON SC H74939406S0 EACH $725.00 272 $507.50 $362.50 $580.00 65% 80% 50% 50% 65% 65% 65% 48117733 CARDIAC CATH CCL BOSTON SC M001465090 EACH $105.00 272 $73.50 $52.50 $84.00 65% 80% 50% 50% 65% 65% 65% 48117741 CARDIAC CATH CCL BOSTON SC M001468540 EACH $183.00 272 $128.10 $91.50 $146.40 65% 80% 50% 50% 65% 65% 65% 48104954 CARDIAC CATH CCL BOSTON SCIENT H74939406XS0 EACH $825.00 272 $577.50 $412.50 $660.00 65% 80% 50% 50% 65% 65% 65% 48104970 CARDIAC CATH CCL BOSTON SCIENT M001465260 EACH $135.00 272 $94.50 $67.50 $108.00 65% 80% 50% 50% 65% 65% 65% 48110795 CARDIAC CATH CCL BOSTON SCIENT M635TU70010 EACH "$2,500.00 " 272 "$1,750.00 " "$1,250.00 " "$2,000.00 " 65% 80% 50% 50% 65% 65% 65% 48110803 CARDIAC CATH CCL BOSTON SCIENT M635TU70020 EACH "$2,500.00 " 272 "$1,750.00 " "$1,250.00 " "$2,000.00 " 65% 80% 50% 50% 65% 65% 65% 48110811 CARDIAC CATH CCL BOSTON SCIENT M635TU70040 EACH "$2,500.00 " 272 "$1,750.00 " "$1,250.00 " "$2,000.00 " 65% 80% 50% 50% 65% 65% 65% 48110746 CARDIAC CATH CCL BOSTON SCIENT M635WU50200 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48110753 CARDIAC CATH CCL BOSTON SCIENT M635WU50240 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48110761 CARDIAC CATH CCL BOSTON SCIENT M635WU50270 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48110779 CARDIAC CATH CCL BOSTON SCIENT M635WU50310 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48110787 CARDIAC CATH CCL BOSTON SCIENT M635WU50350 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48101935 CARDIAC CATH CCL BOSTON SCIENTIF 500-55106 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48101943 CARDIAC CATH CCL BOSTON SCIENTIF 500-55112 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48101950 CARDIAC CATH CCL BOSTON SCIENTIF 500-55118 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48101968 CARDIAC CATH CCL BOSTON SCIENTIF 500-55124 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48101976 CARDIAC CATH CCL BOSTON SCIENTIF 500-55130 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48101984 CARDIAC CATH CCL BOSTON SCIENTIF 500-55140 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48101992 CARDIAC CATH CCL BOSTON SCIENTIF 500-55150 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48105571 CARDIAC CATH CCL BOSTON SCIENTIF 500-56112 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48105589 CARDIAC CATH CCL BOSTON SCIENTIF 500-56130 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48105597 CARDIAC CATH CCL BOSTON SCIENTIF 500-56140 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48105605 CARDIAC CATH CCL BOSTON SCIENTIF 500-56150 EACH "$6,988.00 " 272 "$4,891.60 " "$3,494.00 " "$5,590.40 " 65% 80% 50% 50% 65% 65% 65% 48199566 CARDIAC CATH CCL BS 15-962B EACH C1769 $10.00 278 $7.00 $5.00 $8.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48198055 CARDIAC CATH CCL BS 39171-05047 EACH C1725 $534.00 278 $373.80 $267.00 $427.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48198642 CARDIAC CATH CCL BS H749393033000 EACH C1769 $875.00 278 $612.50 $437.50 $700.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48198733 CARDIAC CATH CCL BS M001465630 EACH $60.00 272 $42.00 $30.00 $48.00 65% 80% 50% 50% 65% 65% 65% 48198741 CARDIAC CATH CCL BS M001466010 EACH $183.00 272 $128.10 $91.50 $146.40 65% 80% 50% 50% 65% 65% 65% 48199558 CARDIAC CATH CCL CARDH D2310C EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48105621 CARDIAC CATH CCL CARDINAL HEALTH SANCGCLCHF EACH $143.00 272 $100.10 $71.50 $114.40 65% 80% 50% 50% 65% 65% 65% 48117592 CARDIAC CATH CCL COOK G00993 EACH $38.00 272 $26.60 $19.00 $30.40 65% 80% 50% 50% 65% 65% 65% 48104327 CARDIAC CATH CCL COOK G00994 EACH $45.00 272 $31.50 $22.50 $36.00 65% 80% 50% 50% 65% 65% 65% 48104947 CARDIAC CATH CCL COOK G00995 EACH $45.00 272 $31.50 $22.50 $36.00 65% 80% 50% 50% 65% 65% 65% 48199673 CARDIAC CATH CCL COOK G07369 EACH $133.00 272 $93.10 $66.50 $106.40 65% 80% 50% 50% 65% 65% 65% 48117600 CARDIAC CATH CCL COOK G08867 EACH $165.00 272 $115.50 $82.50 $132.00 65% 80% 50% 50% 65% 65% 65% 48117618 CARDIAC CATH CCL COOK G09809 EACH $196.00 272 $137.20 $98.00 $156.80 65% 80% 50% 50% 65% 65% 65% 48117626 CARDIAC CATH CCL COOK G09810 EACH $203.00 272 $142.10 $101.50 $162.40 65% 80% 50% 50% 65% 65% 65% 48117634 CARDIAC CATH CCL COOK G56231 EACH $210.00 272 $147.00 $105.00 $168.00 65% 80% 50% 50% 65% 65% 65% 48117642 CARDIAC CATH CCL COOK G56232 EACH $210.00 272 $147.00 $105.00 $168.00 65% 80% 50% 50% 65% 65% 65% 48117659 CARDIAC CATH CCL COVIDIEN GLS323 EACH $163.00 272 $114.10 $81.50 $130.40 65% 80% 50% 50% 65% 65% 65% 48117899 CARDIAC CATH CCL COVIDIEN SL5637 EACH $233.00 272 $163.10 $116.50 $186.40 65% 80% 50% 50% 65% 65% 65% 48117907 CARDIAC CATH CCL COVIDIEN SL693 EACH $248.00 272 $173.60 $124.00 $198.40 65% 80% 50% 50% 65% 65% 65% 48197958 CARDIAC CATH CCL CSI 210-103-5UU EACH $500.00 272 $350.00 $250.00 $400.00 65% 80% 50% 50% 65% 65% 65% 48198022 CARDIAC CATH CCL CSI 220-15-1000U EACH "$1,375.00 " 272 $962.50 $687.50 "$1,100.00 " 65% 80% 50% 50% 65% 65% 65% 48199368 CARDIAC CATH CCL EDWARDS LS 9355NF23A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199376 CARDIAC CATH CCL EDWARDS LS 9355NF26A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199384 CARDIAC CATH CCL EDWARDS LS 9355NF29A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199210 CARDIAC CATH CCL EDWARDS LS 9600CM20A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199228 CARDIAC CATH CCL EDWARDS LS 9600CM23A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199236 CARDIAC CATH CCL EDWARDS LS 9600CM26A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199244 CARDIAC CATH CCL EDWARDS LS 9600CM29A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199285 CARDIAC CATH CCL EDWARDS LS 9600CT20A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199293 CARDIAC CATH CCL EDWARDS LS 9600CT23A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199301 CARDIAC CATH CCL EDWARDS LS 9600CT26A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199319 CARDIAC CATH CCL EDWARDS LS 9600CT29A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199251 CARDIAC CATH CCL EDWARDS LS S3UCM220A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199269 CARDIAC CATH CCL EDWARDS LS S3UCM223A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199277 CARDIAC CATH CCL EDWARDS LS S3UCM226A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199327 CARDIAC CATH CCL EDWARDS LS S3USTA120A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199335 CARDIAC CATH CCL EDWARDS LS S3USTA123A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199343 CARDIAC CATH CCL EDWARDS LS S3USTA126A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199350 CARDIAC CATH CCL EDWARDS LS S3UTA129A EACH "$48,750.00 " 272 "$34,125.00 " "$24,375.00 " "$39,000.00 " 65% 80% 50% 50% 65% 65% 65% 48198428 CARDIAC CATH CCL EDWARDSLS 831F75 EACH C1751 $265.00 278 $185.50 $132.50 $212.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48117543 CARDIAC CATH CCL GORE DSF2433 EACH $318.00 272 $222.60 $159.00 $254.40 65% 80% 50% 50% 65% 65% 65% 48105720 CARDIAC CATH CCL INARI 21-201 EACH "$27,500.00 " 272 "$19,250.00 " "$13,750.00 " "$22,000.00 " 65% 80% 50% 50% 65% 65% 65% 48105738 CARDIAC CATH CCL INARI 22-101 EACH "$27,500.00 " 272 "$19,250.00 " "$13,750.00 " "$22,000.00 " 65% 80% 50% 50% 65% 65% 65% 48111959 CARDIAC CATH CCL INARI 40-102 EACH "$16,250.00 " 270 "$11,375.00 " "$8,125.00 " "$13,000.00 " 65% 80% 50% 50% 65% 65% 65% 48111967 CARDIAC CATH CCL INARI 50-101 EACH "$6,250.00 " 270 "$4,375.00 " "$3,125.00 " "$5,000.00 " 65% 80% 50% 50% 65% 65% 65% 48111975 CARDIAC CATH CCL INARI 51-101 EACH "$6,250.00 " 270 "$4,375.00 " "$3,125.00 " "$5,000.00 " 65% 80% 50% 50% 65% 65% 65% 48111942 CARDIAC CATH CCL INARI FT-PPP EACH "$27,500.00 " 270 "$19,250.00 " "$13,750.00 " "$22,000.00 " 65% 80% 50% 50% 65% 65% 65% 48104293 CARDIAC CATH CCL MEDLINE DYNJE5920 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48197271 CARDIAC CATH CCL MEDTRON 051101A EACH $19.00 272 $13.30 $9.50 $15.20 65% 80% 50% 50% 65% 65% 65% 48199541 CARDIAC CATH CCL MEDTRON 071101A EACH $19.00 272 $13.30 $9.50 $15.20 65% 80% 50% 50% 65% 65% 65% 48197966 CARDIAC CATH CCL MEDTRON 210-153-5UU EACH C1725 $563.00 278 $394.10 $281.50 $450.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48198444 CARDIAC CATH CCL MEDTRON ASG06023W EACH $35.00 272 $24.50 $17.50 $28.00 65% 80% 50% 50% 65% 65% 65% 48198451 CARDIAC CATH CCL MEDTRON CATRXKIT EACH C1757 "$4,850.00 " 278 "$3,395.00 " "$2,425.00 " "$3,880.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48198527 CARDIAC CATH CCL MEDTRON EUP2010X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198535 CARDIAC CATH CCL MEDTRON EUP2012X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198543 CARDIAC CATH CCL MEDTRON EUP2015X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198550 CARDIAC CATH CCL MEDTRON EUP2510X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198568 CARDIAC CATH CCL MEDTRON EUP2512X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198576 CARDIAC CATH CCL MEDTRON EUP2515X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198584 CARDIAC CATH CCL MEDTRON EUP2520X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198592 CARDIAC CATH CCL MEDTRON EUP3012X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198600 CARDIAC CATH CCL MEDTRON EUP3015X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198618 CARDIAC CATH CCL MEDTRON EUP3512X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198709 CARDIAC CATH CCL MEDTRON LA6EBU375 EACH $113.00 272 $79.10 $56.50 $90.40 65% 80% 50% 50% 65% 65% 65% 48198717 CARDIAC CATH CCL MEDTRON LA7EBU35 EACH $113.00 272 $79.10 $56.50 $90.40 65% 80% 50% 50% 65% 65% 65% 48198725 CARDIAC CATH CCL MEDTRON LA7JR40SH EACH $113.00 272 $79.10 $56.50 $90.40 65% 80% 50% 50% 65% 65% 65% 48198758 CARDIAC CATH CCL MEDTRON NCEUP2008X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198766 CARDIAC CATH CCL MEDTRON NCEUP2012X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198774 CARDIAC CATH CCL MEDTRON NCEUP2508X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198782 CARDIAC CATH CCL MEDTRON NCEUP2512X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198790 CARDIAC CATH CCL MEDTRON NCEUP2520X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198808 CARDIAC CATH CCL MEDTRON NCEUP27508X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198816 CARDIAC CATH CCL MEDTRON NCEUP27512X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198824 CARDIAC CATH CCL MEDTRON NCEUP27520X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198832 CARDIAC CATH CCL MEDTRON NCEUP3020X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198840 CARDIAC CATH CCL MEDTRON NCEUP32512X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198857 CARDIAC CATH CCL MEDTRON NCEUP32520X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198865 CARDIAC CATH CCL MEDTRON NCEUP3508X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198873 CARDIAC CATH CCL MEDTRON NCEUP3520X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198881 CARDIAC CATH CCL MEDTRON NCEUP4008X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48198899 CARDIAC CATH CCL MEDTRON NCEUP4020X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48199038 CARDIAC CATH CCL MEDTRON RONYX20012UX EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48199046 CARDIAC CATH CCL MEDTRON RONYX20015UX EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48199053 CARDIAC CATH CCL MEDTRON RONYX20018UX EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48199061 CARDIAC CATH CCL MEDTRON RONYX20022UX EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48199079 CARDIAC CATH CCL MEDTRON RONYX20030UX EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48199087 CARDIAC CATH CCL MEDTRON RONYX22534UX EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48199095 CARDIAC CATH CCL MEDTRON RONYX22538UX EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48199129 CARDIAC CATH CCL MEDTRON SPL12506X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48199137 CARDIAC CATH CCL MEDTRON SPL12510X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48199145 CARDIAC CATH CCL MEDTRON SPL12512X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48199152 CARDIAC CATH CCL MEDTRON SPL12515X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48199186 CARDIAC CATH CCL MEDTRON TELA6F EACH "$1,125.00 " 272 $787.50 $562.50 $900.00 65% 80% 50% 50% 65% 65% 65% 48199160 CARDIAC CATH CCL MEDTRON TELE7F EACH "$1,125.00 " 272 $787.50 $562.50 $900.00 65% 80% 50% 50% 65% 65% 65% 48101729 CARDIAC CATH CCL MEDTRONIC D-EVPROP2329US EACH "$12,425.00 " 272 "$8,697.50 " "$6,212.50 " "$9,940.00 " 65% 80% 50% 50% 65% 65% 65% 48101737 CARDIAC CATH CCL MEDTRONIC D-EVPROP34US EACH "$12,425.00 " 272 "$8,697.50 " "$6,212.50 " "$9,940.00 " 65% 80% 50% 50% 65% 65% 65% 48112106 CARDIAC CATH CCL MEDTRONIC ENS-1018 EACH "$16,250.00 " 272 "$11,375.00 " "$8,125.00 " "$13,000.00 " 65% 80% 50% 50% 65% 65% 65% 48112114 CARDIAC CATH CCL MEDTRONIC ENS-1020 EACH "$16,250.00 " 272 "$11,375.00 " "$8,125.00 " "$13,000.00 " 65% 80% 50% 50% 65% 65% 65% 48112122 CARDIAC CATH CCL MEDTRONIC ENS-1022 EACH "$16,250.00 " 272 "$11,375.00 " "$8,125.00 " "$13,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101778 CARDIAC CATH CCL MEDTRONIC ENVEOR-N-US EACH "$11,175.00 " 272 "$7,822.50 " "$5,587.50 " "$8,940.00 " 65% 80% 50% 50% 65% 65% 65% 48101760 CARDIAC CATH CCL MEDTRONIC ENVEOR-US EACH "$11,175.00 " 272 "$7,822.50 " "$5,587.50 " "$8,940.00 " 65% 80% 50% 50% 65% 65% 65% 48101745 CARDIAC CATH CCL MEDTRONIC ENVPRO-14-US EACH "$11,175.00 " 272 "$7,822.50 " "$5,587.50 " "$8,940.00 " 65% 80% 50% 50% 65% 65% 65% 48101752 CARDIAC CATH CCL MEDTRONIC ENVPRO-16-US EACH "$11,175.00 " 272 "$7,822.50 " "$5,587.50 " "$8,940.00 " 65% 80% 50% 50% 65% 65% 65% 48117550 CARDIAC CATH CCL MEDTRONIC EUP2020X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48117568 CARDIAC CATH CCL MEDTRONIC EUP3020X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48117576 CARDIAC CATH CCL MEDTRONIC EUP3520X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48101653 CARDIAC CATH CCL MEDTRONIC EVOLUTPRO-23-US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101661 CARDIAC CATH CCL MEDTRONIC EVOLUTPRO-26-US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101679 CARDIAC CATH CCL MEDTRONIC EVOLUTPRO-29-US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101695 CARDIAC CATH CCL MEDTRONIC EVOLUTR-23-US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101703 CARDIAC CATH CCL MEDTRONIC EVOLUTR-26-US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101711 CARDIAC CATH CCL MEDTRONIC EVOLUTR-29-US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101687 CARDIAC CATH CCL MEDTRONIC EVOLUTR-34-US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101612 CARDIAC CATH CCL MEDTRONIC EVPROPLUS-23US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48117584 CARDIAC CATH CCL MEDTRONIC EVPROPLUS-23US EACH "$75,000.00 " 272 "$52,500.00 " "$37,500.00 " "$60,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101620 CARDIAC CATH CCL MEDTRONIC EVPROPLUS-26US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101638 CARDIAC CATH CCL MEDTRONIC EVPROPLUS-26US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48101646 CARDIAC CATH CCL MEDTRONIC EVPROPLUS-34US EACH "$45,000.00 " 272 "$31,500.00 " "$22,500.00 " "$36,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199772 CARDIAC CATH CCL MEDTRONIC GWBC30 EACH $488.00 272 $341.60 $244.00 $390.40 65% 80% 50% 50% 65% 65% 65% 48117725 CARDIAC CATH CCL MEDTRONIC LA7AL75 EACH $113.00 272 $79.10 $56.50 $90.40 65% 80% 50% 50% 65% 65% 65% 48104962 CARDIAC CATH CCL MEDTRONIC LA7JR40 EACH $113.00 272 $79.10 $56.50 $90.40 65% 80% 50% 50% 65% 65% 65% 48101802 CARDIAC CATH CCL MEDTRONIC L-ENVPRO-14-US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48101810 CARDIAC CATH CCL MEDTRONIC L-ENVPRO-1623US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48101828 CARDIAC CATH CCL MEDTRONIC L-ENVPRO-16-US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48101786 CARDIAC CATH CCL MEDTRONIC L-EVPROP2329US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48101794 CARDIAC CATH CCL MEDTRONIC L-EVPROP34US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48101836 CARDIAC CATH CCL MEDTRONIC LS-ENVEOR23US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48101844 CARDIAC CATH CCL MEDTRONIC LS-ENVEOR2629US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48101851 CARDIAC CATH CCL MEDTRONIC LS-ENVEOR-34-US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48101869 CARDIAC CATH CCL MEDTRONIC LS-MDT2-23-US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48101877 CARDIAC CATH CCL MEDTRONIC LS-MDT2-2629-US EACH "$1,275.00 " 272 $892.50 $637.50 "$1,020.00 " 65% 80% 50% 50% 65% 65% 65% 48117758 CARDIAC CATH CCL MEDTRONIC NCEUP4508X EACH $363.00 272 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% 65% 65% 48112098 CARDIAC CATH CCL MEDTRONIC PB1018 EACH "$38,250.00 " 272 "$26,775.00 " "$19,125.00 " "$30,600.00 " 65% 80% 50% 50% 65% 65% 65% 48105670 CARDIAC CATH CCL MEDTRONIC RONYX20026UX EACH $35.00 272 $24.50 $17.50 $28.00 65% 80% 50% 50% 65% 65% 65% 48117865 CARDIAC CATH CCL MEDTRONIC RONYX22530UX EACH "$3,238.00 " 272 "$2,266.60 " "$1,619.00 " "$2,590.40 " 65% 80% 50% 50% 65% 65% 65% 48117873 CARDIAC CATH CCL MEDTRONIC RONYX45022UX EACH "$3,238.00 " 272 "$2,266.60 " "$1,619.00 " "$2,590.40 " 65% 80% 50% 50% 65% 65% 65% 48112031 CARDIAC CATH CCL MEDTRONIC VAMF2222C100E EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48112049 CARDIAC CATH CCL MEDTRONIC VAMF2222C150E EACH "$26,356.00 " 272 "$18,449.20 " "$13,178.00 " "$21,084.80 " 65% 80% 50% 50% 65% 65% 65% 48112056 CARDIAC CATH CCL MEDTRONIC VAMF2424C100E EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48112064 CARDIAC CATH CCL MEDTRONIC VAMF2424C150E EACH "$26,356.00 " 272 "$18,449.20 " "$13,178.00 " "$21,084.80 " 65% 80% 50% 50% 65% 65% 65% 48112072 CARDIAC CATH CCL MEDTRONIC VAMF2626C100E EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48112080 CARDIAC CATH CCL MEDTRONIC VAMF2626C150E EACH "$26,356.00 " 272 "$18,449.20 " "$13,178.00 " "$21,084.80 " 65% 80% 50% 50% 65% 65% 65% 48117402 CARDIAC CATH CCL MERIT MED 57538CSHK-WOR EACH $201.00 272 $140.70 $100.50 $160.80 65% 80% 50% 50% 65% 65% 65% 48117774 CARDIAC CATH CCL MERIT MED PHR5F11021SSC EACH $95.00 272 $66.50 $47.50 $76.00 65% 80% 50% 50% 65% 65% 65% 48117782 CARDIAC CATH CCL MERIT MED PHR6F11021SC EACH $95.00 272 $66.50 $47.50 $76.00 65% 80% 50% 50% 65% 65% 65% 48117790 CARDIAC CATH CCL MERIT MED PLS-2506 EACH $69.00 272 $48.30 $34.50 $55.20 65% 80% 50% 50% 65% 65% 65% 48117808 CARDIAC CATH CCL MERIT MED PRO-8F-11-035 EACH $17.00 272 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 48117816 CARDIAC CATH CCL MERIT MED PSI-8F-23-035 EACH $17.00 272 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 48117428 CARDIAC CATH CCL MERIT MEDICAL 7531-13 EACH $23.00 272 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% 65% 65% 48117436 CARDIAC CATH CCL MERIT MEDICAL 7533-23 EACH $23.00 272 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% 65% 65% 48117444 CARDIAC CATH CCL MERIT MEDICAL 7533-33 EACH $23.00 272 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% 65% 65% 48117451 CARDIAC CATH CCL MERIT MEDICAL 7534-13 EACH $23.00 272 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% 65% 65% 48117469 CARDIAC CATH CCL MERIT MEDICAL 7534-23 EACH $23.00 272 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% 65% 65% 48117477 CARDIAC CATH CCL MERIT MEDICAL 7700-20 EACH $23.00 272 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% 65% 65% 48117915 CARDIAC CATH CCL MERIT MEDICAL SRB24LBAC EACH $68.00 272 $47.60 $34.00 $54.40 65% 80% 50% 50% 65% 65% 65% 48117923 CARDIAC CATH CCL MERIT MEDICAL SRB29LBAC EACH $68.00 272 $47.60 $34.00 $54.40 65% 80% 50% 50% 65% 65% 65% 48104996 CARDIAC CATH CCL MERIT MEDICL PID6F11021SSC EACH $65.00 272 $45.50 $32.50 $52.00 65% 80% 50% 50% 65% 65% 65% 48199632 CARDIAC CATH CCL MERITM EACH C1769 $7.00 278 $4.90 $3.50 $5.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48198097 CARDIAC CATH CCL MERITM 6682-E1 EACH $19.00 272 $13.30 $9.50 $15.20 65% 80% 50% 50% 65% 65% 65% 48198113 CARDIAC CATH CCL MERITM 7501-H1 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198121 CARDIAC CATH CCL MERITM 7503-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198139 CARDIAC CATH CCL MERITM 7503-21 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198147 CARDIAC CATH CCL MERITM 7507-13 EACH $23.00 272 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% 65% 65% 48198154 CARDIAC CATH CCL MERITM 7507-23 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198162 CARDIAC CATH CCL MERITM 7507-33 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198170 CARDIAC CATH CCL MERITM 7509-11 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198188 CARDIAC CATH CCL MERITM 7510-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198196 CARDIAC CATH CCL MERITM 7510-23 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198204 CARDIAC CATH CCL MERITM 7511-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198212 CARDIAC CATH CCL MERITM 7512-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198220 CARDIAC CATH CCL MERITM 7513-B3 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198238 CARDIAC CATH CCL MERITM 7521-33 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198246 CARDIAC CATH CCL MERITM 7521-F1 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198253 CARDIAC CATH CCL MERITM 7523-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198261 CARDIAC CATH CCL MERITM 7523-21 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198279 CARDIAC CATH CCL MERITM 7527-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198287 CARDIAC CATH CCL MERITM 7527-23 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198295 CARDIAC CATH CCL MERITM 7529-11 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198303 CARDIAC CATH CCL MERITM 7529-23 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198311 CARDIAC CATH CCL MERITM 7532-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198329 CARDIAC CATH CCL MERITM 7533-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198337 CARDIAC CATH CCL MERITM 7574-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198345 CARDIAC CATH CCL MERITM 7574-21 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198352 CARDIAC CATH CCL MERITM 7574-33 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198360 CARDIAC CATH CCL MERITM 7574-43 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198378 CARDIAC CATH CCL MERITM 7601-13 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198386 CARDIAC CATH CCL MERITM 7601-21 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198394 CARDIAC CATH CCL MERITM 7601-43 EACH $28.00 272 $19.60 $14.00 $22.40 65% 80% 50% 50% 65% 65% 65% 48198402 CARDIAC CATH CCL MERITM 7700-10 EACH $28.00 272 $19.60 $14.00 $22.40 65% 80% 50% 50% 65% 65% 65% 48198410 CARDIAC CATH CCL MERITM 7701-20 EACH $24.00 272 $16.80 $12.00 $19.20 65% 80% 50% 50% 65% 65% 65% 48198436 CARDIAC CATH CCL MERITM AD21T41W EACH $8.00 272 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% 48198469 CARDIAC CATH CCL MERITM CCX010 EACH $11.00 272 $7.70 $5.50 $8.80 65% 80% 50% 50% 65% 65% 65% 48198477 CARDIAC CATH CCL MERITM CON-006-01 EACH $28.00 272 $19.60 $14.00 $22.40 65% 80% 50% 50% 65% 65% 65% 48199780 CARDIAC CATH CCL MERITM HPF480E EACH $13.00 272 $9.10 $6.50 $10.40 65% 80% 50% 50% 65% 65% 65% 48198659 CARDIAC CATH CCL MERITM IQ35F150J15 EACH $16.00 272 $11.20 $8.00 $12.80 65% 80% 50% 50% 65% 65% 65% 48198667 CARDIAC CATH CCL MERITM IQ35F150J3 EACH $24.00 272 $16.80 $12.00 $19.20 65% 80% 50% 50% 65% 65% 65% 48198675 CARDIAC CATH CCL MERITM IQ35F180J3 EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 48198683 CARDIAC CATH CCL MERITM IQ35F260J3 EACH $24.00 272 $16.80 $12.00 $19.20 65% 80% 50% 50% 65% 65% 65% 48199525 CARDIAC CATH CCL MERITM IQ38F150S EACH C1769 $7.00 278 $4.90 $3.50 $5.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48198691 CARDIAC CATH CCL MERITM K11-01298 EACH $66.00 272 $46.20 $33.00 $52.80 65% 80% 50% 50% 65% 65% 65% 48199574 CARDIAC CATH CCL MERITM MDD100 EACH $50.00 272 $35.00 $25.00 $40.00 65% 80% 50% 50% 65% 65% 65% 48198907 CARDIAC CATH CCL MERITM PLS-1006 EACH $69.00 272 $48.30 $34.50 $55.20 65% 80% 50% 50% 65% 65% 65% 48198915 CARDIAC CATH CCL MERITM PLS-1008 EACH $69.00 272 $48.30 $34.50 $55.20 65% 80% 50% 50% 65% 65% 65% 48198923 CARDIAC CATH CCL MERITM PLS-2506 EACH $69.00 272 $48.30 $34.50 $55.20 65% 80% 50% 50% 65% 65% 65% 48198931 CARDIAC CATH CCL MERITM PRO-4F-11-035 EACH $50.00 272 $35.00 $25.00 $40.00 65% 80% 50% 50% 65% 65% 65% 48198949 CARDIAC CATH CCL MERITM PRO-5F-11-038 EACH $17.00 272 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 48198956 CARDIAC CATH CCL MERITM PRO-6F-11-038 EACH $17.00 272 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 48198964 CARDIAC CATH CCL MERITM PRO-7F-11-035 EACH $17.00 272 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 48198972 CARDIAC CATH CCL MERITM PRO-7F-11-038 EACH $17.00 272 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 48198980 CARDIAC CATH CCL MERITM PRO-8F-11 EACH $17.00 272 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 48198998 CARDIAC CATH CCL MERITM PRO-8F-11-038 EACH $17.00 272 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 48199004 CARDIAC CATH CCL MERITM PSI EACH $17.00 272 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 48199012 CARDIAC CATH CCL MERITM PSI-5F-23-035 EACH $61.00 272 $42.70 $30.50 $48.80 65% 80% 50% 50% 65% 65% 65% 48199020 CARDIAC CATH CCL MERITM PSI-6F-23-035 EACH $61.00 272 $42.70 $30.50 $48.80 65% 80% 50% 50% 65% 65% 65% 48199533 CARDIAC CATH CCL OSCOR 6650EZ EACH $14.00 272 $9.80 $7.00 $11.20 65% 80% 50% 50% 65% 65% 65% 48199517 CARDIAC CATH CCL OSCOR R1547 EACH $3.00 272 $2.10 $1.50 $2.40 65% 80% 50% 50% 65% 65% 65% 48111876 CARDIAC CATH CCL P CATH IMPLANT CARDIO MEMS EACH "$72,039.00 " 481 "$50,427.30 " "$36,019.50 " "$57,631.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48111777 CARDIAC CATH CCL P EKOS-ARTER OR VENOUS INF EACH "$7,155.00 " 361 "$5,008.50 " "$3,577.50 " "$5,724.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48111751 CARDIAC CATH CCL P EKOS-ARTERIAL INFUSION EACH "$11,926.00 " 361 "$8,348.20 " "$5,963.00 " "$9,540.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48111769 CARDIAC CATH CCL P EKOS-VENOUS INFUSION EACH "$7,155.00 " 361 "$5,008.50 " "$3,577.50 " "$5,724.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105555 CARDIAC CATH CCL P EP ABLATION OF AV NODE EACH "$15,197.00 " 481 "$10,637.90 " "$7,598.50 " "$12,157.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105514 CARDIAC CATH CCL P EP STUDY EACH "$15,197.00 " 480 "$10,637.90 " "$7,598.50 " "$12,157.60 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105548 CARDIAC CATH CCL P EP STUDY W/ PVC/VT ABLAT EACH "$53,662.00 " 481 "$37,563.40 " "$26,831.00 " "$42,929.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105522 CARDIAC CATH CCL P EP STUDY W/AFIB ABLATION EACH "$53,662.00 " 481 "$37,563.40 " "$26,831.00 " "$42,929.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105563 CARDIAC CATH CCL P EP STUDY W/POS SVT ABLAT EACH "$53,662.00 " 481 "$37,563.40 " "$26,831.00 " "$42,929.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105530 CARDIAC CATH CCL P EP STUDY/W AFLUT ABLAT EACH "$53,662.00 " 481 "$37,563.40 " "$26,831.00 " "$42,929.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48111850 CARDIAC CATH CCL P IMPELLA REMOVAL EACH "$28,376.00 " 360 "$19,863.20 " "$14,188.00 " "$22,700.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48111868 CARDIAC CATH CCL P IMPELLA REPOSITIONING EACH "$28,376.00 " 360 "$19,863.20 " "$14,188.00 " "$22,700.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105845 CARDIAC CATH CCL P MITRACLIP-ADDITIONL CLIP EACH "$69,758.00 " 360 "$48,830.60 " "$34,879.00 " "$55,806.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48111900 CARDIAC CATH CCL P PERQ TRANSCATH CLOS PDA EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48111934 CARDIAC CATH CCL P PERQ TRANSCATH CLS EACH EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48111926 CARDIAC CATH CCL P PERQ TRANSCTH CLS AORTIC EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48111918 CARDIAC CATH CCL P PERQ TRANSCTH CLS MITRAL EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48111793 CARDIAC CATH CCL P PRIM ART M-THRM SBSQ VSL EACH "$30,108.00 " 361 "$21,075.60 " "$15,054.00 " "$24,086.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48111785 CARDIAC CATH CCL P PRIM ART M-THRMBC 1 VSL EACH "$25,108.00 " 481 "$17,575.60 " "$12,554.00 " "$20,086.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48111835 CARDIAC CATH CCL P PRQ CORON MECH THROMBECT EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48111884 CARDIAC CATH CCL P REPL AORTIC VALVE PERQ EACH "$40,160.00 " 360 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48111801 CARDIAC CATH CCL P SEC ART THROMBECT ADD-ON EACH "$35,108.00 " 361 "$24,575.60 " "$17,554.00 " "$28,086.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105829 CARDIAC CATH CCL P TAVR -AORTIC APPROACH EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105803 CARDIAC CATH CCL P TAVR-OPEN AXILLARY ARTRY EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105795 CARDIAC CATH CCL P TAVR-OPEN FEMORAL ARTERY EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105811 CARDIAC CATH CCL P TAVR-OPEN ILIAC ARTERY EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105837 CARDIAC CATH CCL P TAVR-W/VALVE TRANSAPICAL EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48111892 CARDIAC CATH CCL P TRANSCATH CLOSURE OF ASD EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105779 CARDIAC CATH CCL P V IN V (PULMONARY) EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105787 CARDIAC CATH CCL P V IN V (TRICUSPID) EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48111827 CARDIAC CATH CCL P VEN MECH THRMB REPEAT TX EACH "$7,155.00 " 481 "$5,008.50 " "$3,577.50 " "$5,724.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48111819 CARDIAC CATH CCL P VENOUS MECH THROMBECTOMY EACH "$25,108.00 " 361 "$17,575.60 " "$12,554.00 " "$20,086.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105753 CARDIAC CATH CCL P V-V MITRAL PERC APPROACH EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105761 CARDIAC CATH CCL P V-V MITRAL-W/TRANSTH EXP EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48101927 CARDIAC CATH CCL PENUMBRA CATRXKIT EACH "$4,850.00 " 272 "$3,395.00 " "$2,425.00 " "$3,880.00 " 65% 80% 50% 50% 65% 65% 65% 48101919 CARDIAC CATH CCL PENUMBRA IAPS3 EACH $913.00 272 $639.10 $456.50 $730.40 65% 80% 50% 50% 65% 65% 65% 48101885 CARDIAC CATH CCL PENUMBRA LITNG12HTORQ115 EACH "$17,025.00 " 272 "$11,917.50 " "$8,512.50 " "$13,620.00 " 65% 80% 50% 50% 65% 65% 65% 48101893 CARDIAC CATH CCL PENUMBRA LITNG12XTORQ100 EACH "$17,025.00 " 272 "$11,917.50 " "$8,512.50 " "$13,620.00 " 65% 80% 50% 50% 65% 65% 65% 48101901 CARDIAC CATH CCL PENUMBRA SEP12 EACH "$4,863.00 " 272 "$3,404.10 " "$2,431.50 " "$3,890.40 " 65% 80% 50% 50% 65% 65% 65% 48105712 CARDIAC CATH CCL REMINGTON FL-601-97 EACH $68.00 272 $47.60 $34.00 $54.40 65% 80% 50% 50% 65% 65% 65% 48117931 CARDIAC CATH CCL SHOCKWAVE C2IVL2512 EACH C1761 "$11,750.00 " 278 "$8,225.00 " "$5,875.00 " "$9,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48117949 CARDIAC CATH CCL SHOCKWAVE C2IVL3012 EACH C1761 "$11,750.00 " 278 "$8,225.00 " "$5,875.00 " "$9,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48117956 CARDIAC CATH CCL SHOCKWAVE C2IVL3512 EACH C1761 "$11,750.00 " 278 "$8,225.00 " "$5,875.00 " "$9,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48117964 CARDIAC CATH CCL SHOCKWAVE C2IVL4012 EACH C1761 "$11,750.00 " 278 "$8,225.00 " "$5,875.00 " "$9,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48117972 CARDIAC CATH CCL SHOCKWAVE M5PIVL3560 EACH C1761 "$8,625.00 " 278 "$6,037.50 " "$4,312.50 " "$6,900.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48117980 CARDIAC CATH CCL SHOCKWAVE M5PIVL4060 EACH C1761 "$8,625.00 " 278 "$6,037.50 " "$4,312.50 " "$6,900.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48117998 CARDIAC CATH CCL SHOCKWAVE M5PIVL4560 EACH C1761 "$8,625.00 " 278 "$6,037.50 " "$4,312.50 " "$6,900.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118004 CARDIAC CATH CCL SHOCKWAVE M5PIVL5060 EACH C1761 "$8,625.00 " 278 "$6,037.50 " "$4,312.50 " "$6,900.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118012 CARDIAC CATH CCL SHOCKWAVE M5PIVL5560 EACH C1761 "$8,625.00 " 278 "$6,037.50 " "$4,312.50 " "$6,900.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118020 CARDIAC CATH CCL SHOCKWAVE M5PIVL6060 EACH C1761 "$8,625.00 " 278 "$6,037.50 " "$4,312.50 " "$6,900.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118038 CARDIAC CATH CCL SHOCKWAVE M5PIVL6560 EACH C1761 "$8,625.00 " 278 "$6,037.50 " "$4,312.50 " "$6,900.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118046 CARDIAC CATH CCL SHOCKWAVE M5PIVL7060 EACH C1761 "$8,625.00 " 278 "$6,037.50 " "$4,312.50 " "$6,900.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118053 CARDIAC CATH CCL SHOCKWAVE S4IVLK2540 EACH C1761 "$6,875.00 " 278 "$4,812.50 " "$3,437.50 " "$5,500.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118061 CARDIAC CATH CCL SHOCKWAVE S4IVLK3040 EACH C1761 "$6,875.00 " 278 "$4,812.50 " "$3,437.50 " "$5,500.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118079 CARDIAC CATH CCL SHOCKWAVE S4IVLK3540 EACH C1761 "$6,875.00 " 278 "$4,812.50 " "$3,437.50 " "$5,500.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118087 CARDIAC CATH CCL SHOCKWAVE S4IVLK4040 EACH C1761 "$6,875.00 " 278 "$4,812.50 " "$3,437.50 " "$5,500.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48105639 CARDIAC CATH CCL SITE RITE US SYS 9001C0197 EACH $38.00 272 $26.60 $19.00 $30.40 65% 80% 50% 50% 65% 65% 65% 48197974 CARDIAC CATH CCL SPECTR 2200-2010 EACH C1725 "$2,000.00 " 278 "$1,400.00 " "$1,000.00 " "$1,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197982 CARDIAC CATH CCL SPECTR 2200-2510 EACH C1725 "$2,000.00 " 278 "$1,400.00 " "$1,000.00 " "$1,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197990 CARDIAC CATH CCL SPECTR 2200-2515 EACH C1725 "$2,000.00 " 278 "$1,400.00 " "$1,000.00 " "$1,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48198006 CARDIAC CATH CCL SPECTR 2200-3015 EACH C1725 "$2,000.00 " 278 "$1,400.00 " "$1,000.00 " "$1,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48198014 CARDIAC CATH CCL SPECTR 2200-3515 EACH C1725 "$2,000.00 " 278 "$1,400.00 " "$1,000.00 " "$1,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48117378 CARDIAC CATH CCL SPECTRANETICS 2200-3010 EACH "$2,000.00 " 272 "$1,400.00 " "$1,000.00 " "$1,600.00 " 65% 80% 50% 50% 65% 65% 65% 48116974 CARDIAC CATH CCL ST. JUDE 407201 EACH $638.00 272 $446.60 $319.00 $510.40 65% 80% 50% 50% 65% 65% 65% 48116982 CARDIAC CATH CCL ST. JUDE 408309 EACH "$2,375.00 " 272 "$1,662.50 " "$1,187.50 " "$1,900.00 " 65% 80% 50% 50% 65% 65% 65% 48198063 CARDIAC CATH CCL STJ 401762 EACH $200.00 272 $140.00 $100.00 $160.00 65% 80% 50% 50% 65% 65% 65% 48199608 CARDIAC CATH CCL STJ 404568 EACH $15.00 272 $10.50 $7.50 $12.00 65% 80% 50% 50% 65% 65% 65% 48199582 CARDIAC CATH CCL STJ 404570 EACH $14.00 272 $9.80 $7.00 $11.20 65% 80% 50% 50% 65% 65% 65% 48199590 CARDIAC CATH CCL STJ 404577 EACH $18.00 272 $12.60 $9.00 $14.40 65% 80% 50% 50% 65% 65% 65% 48199798 CARDIAC CATH CCL STJ 404577 EACH $86.00 272 $60.20 $43.00 $68.80 65% 80% 50% 50% 65% 65% 65% 48199624 CARDIAC CATH CCL STJ 408293 EACH $588.00 272 $411.60 $294.00 $470.40 65% 80% 50% 50% 65% 65% 65% 48106009 CARDIAC CATH CCL SUPPLY LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 48106017 CARDIAC CATH CCL SUPPLY LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 48106108 CARDIAC CATH CCL SUPPLY LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 48106025 CARDIAC CATH CCL SUPPLY LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 48106033 CARDIAC CATH CCL SUPPLY LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 48106041 CARDIAC CATH CCL SUPPLY LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 48106058 CARDIAC CATH CCL SUPPLY LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 48106066 CARDIAC CATH CCL SUPPLY LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 48106074 CARDIAC CATH CCL SUPPLY LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 48106082 CARDIAC CATH CCL SUPPLY LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 48106090 CARDIAC CATH CCL SUPPLY LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 48199616 CARDIAC CATH CCL TELE 5540 EACH $399.00 272 $279.30 $199.50 $319.20 65% 80% 50% 50% 65% 65% 65% 48198048 CARDIAC CATH CCL TERUMO 25-1011 EACH "$1,257.00 " 272 $879.90 $628.50 "$1,005.60 " 65% 80% 50% 50% 65% 65% 65% 48198071 CARDIAC CATH CCL TERUMO 40-6011 EACH $566.00 272 $396.20 $283.00 $452.80 65% 80% 50% 50% 65% 65% 65% 48198089 CARDIAC CATH CCL TERUMO 40-6013 EACH $566.00 272 $396.20 $283.00 $452.80 65% 80% 50% 50% 65% 65% 65% 48117410 CARDIAC CATH CCL TERUMO 60-1060 EACH $23.00 272 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% 65% 65% 48105662 CARDIAC CATH CCL TERUMO 80 1050 EACH $138.00 272 $96.60 $69.00 $110.40 65% 80% 50% 50% 65% 65% 65% 48104186 CARDIAC CATH CCL TERUMO 80-1050 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 48117535 CARDIAC CATH CCL TERUMO DC-PY1512UA1 EACH $383.00 272 $268.10 $191.50 $306.40 65% 80% 50% 50% 65% 65% 65% 48198485 CARDIAC CATH CCL TERUMO DC-RY1512UA1 EACH $335.00 272 $234.50 $167.50 $268.00 65% 80% 50% 50% 65% 65% 65% 48104194 CARDIAC CATH CCL TERUMO DC-RY2021UA2 EACH $450.00 272 $315.00 $225.00 $360.00 65% 80% 50% 50% 65% 65% 65% 48198626 CARDIAC CATH CCL TERUMO GA3501 EACH $528.00 272 $369.60 $264.00 $422.40 65% 80% 50% 50% 65% 65% 65% 48198634 CARDIAC CATH CCL TERUMO GR3501 EACH $386.00 272 $270.20 $193.00 $308.80 65% 80% 50% 50% 65% 65% 65% 48117667 CARDIAC CATH CCL TERUMO GR3508 EACH $103.00 272 $72.10 $51.50 $82.40 65% 80% 50% 50% 65% 65% 65% 48117675 CARDIAC CATH CCL TERUMO GR3509 EACH $103.00 272 $72.10 $51.50 $82.40 65% 80% 50% 50% 65% 65% 65% 48117683 CARDIAC CATH CCL TERUMO GS3508 EACH $103.00 272 $72.10 $51.50 $82.40 65% 80% 50% 50% 65% 65% 65% 48117832 CARDIAC CATH CCL TERUMO RM*AF6G10HAT EACH $107.00 272 $74.90 $53.50 $85.60 65% 80% 50% 50% 65% 65% 65% 48117840 CARDIAC CATH CCL TERUMO RM*BF6F10PA EACH $107.00 272 $74.90 $53.50 $85.60 65% 80% 50% 50% 65% 65% 65% 48117857 CARDIAC CATH CCL TERUMO RM*BF6M10PA EACH $107.00 272 $74.90 $53.50 $85.60 65% 80% 50% 50% 65% 65% 65% 48199103 CARDIAC CATH CCL TERUMO RSS004 EACH $262.00 272 $183.40 $131.00 $209.60 65% 80% 50% 50% 65% 65% 65% 48117881 CARDIAC CATH CCL TERUMO RSS104 EACH $53.00 272 $37.10 $26.50 $42.40 65% 80% 50% 50% 65% 65% 65% 48199111 CARDIAC CATH CCL TERUMO RSS904 EACH $262.00 272 $183.40 $131.00 $209.60 65% 80% 50% 50% 65% 65% 65% 48105688 CARDIAC CATH CCL TERUMO TRB24-REG EACH $105.00 272 $73.50 $52.50 $84.00 65% 80% 50% 50% 65% 65% 65% 48111983 CARDIAC CATH CCL TORAY DMS-1 EACH $220.00 270 $154.00 $110.00 $176.00 65% 80% 50% 50% 65% 65% 65% 48111991 CARDIAC CATH CCL TORAY GMS-1 EACH $388.00 270 $271.60 $194.00 $310.40 65% 80% 50% 50% 65% 65% 65% 48112007 CARDIAC CATH CCL TORAY KMS-1 EACH $325.00 270 $227.50 $162.50 $260.00 65% 80% 50% 50% 65% 65% 65% 48112015 CARDIAC CATH CCL TORAY NMS-1 EACH $100.00 270 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% 65% 65% 48105647 CARDIAC CATH CCL TORAY PTMC 28 EACH "$6,250.00 " 272 "$4,375.00 " "$3,125.00 " "$5,000.00 " 65% 80% 50% 50% 65% 65% 65% 48105654 CARDIAC CATH CCL TORAY PTMC 30 EACH "$6,250.00 " 272 "$4,375.00 " "$3,125.00 " "$5,000.00 " 65% 80% 50% 50% 65% 65% 65% 48112023 CARDIAC CATH CCL TORAY SMS-1 EACH $350.00 270 $245.00 $175.00 $280.00 65% 80% 50% 50% 65% 65% 65% 48197446 CARDIAC CATH CCL VOLC 10300P EACH "$1,625.00 " 272 "$1,137.50 " $812.50 "$1,300.00 " 65% 80% 50% 50% 65% 65% 65% 48105373 CARDIAC CATH CCL-ALCOHOL SEPTAL ABLATION EACH "$27,610.00 " 360 "$19,327.00 " "$13,805.00 " "$22,088.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105332 CARDIAC CATH CCL-AORTIC BALLOON VALVULOPLAS EACH "$12,393.00 " 481 "$8,675.10 " "$6,196.50 " "$9,914.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105282 CARDIAC CATH CCL-ASD PROCEDURE EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105365 CARDIAC CATH CCL-FOREIGN BODY RETRIEVL PROC EACH "$7,155.00 " 360 "$5,008.50 " "$3,577.50 " "$5,724.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105274 CARDIAC CATH CCL-IMPELLA PROCEDURE EACH "$28,376.00 " 360 "$19,863.20 " "$14,188.00 " "$22,700.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105357 CARDIAC CATH CCL-MITRAL CLIP PROCEDURE EACH "$64,758.00 " 360 "$45,330.60 " "$32,379.00 " "$51,806.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105324 CARDIAC CATH CCL-MITRAL VALVULOPLASTY PROC EACH "$25,108.00 " 481 "$17,575.60 " "$12,554.00 " "$20,086.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105316 CARDIAC CATH CCL-PARAVALVULAR LEAK CLOSURE EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105290 CARDIAC CATH CCL-PFO CLOSURES PROCEDURE EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105340 CARDIAC CATH CCL-PULM BALLOON VALVULOPLASTY EACH "$25,107.00 " 481 "$17,574.90 " "$12,553.50 " "$20,085.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105266 CARDIAC CATH CCL-TAVR PROCEDURE EACH "$52,148.00 " 360 "$36,503.60 " "$26,074.00 " "$41,718.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48105308 CARDIAC CATH CCL-VSD PROCEDURE EACH "$40,160.00 " 481 "$28,112.00 " "$20,080.00 " "$32,128.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105258 CARDIAC CATH CCL-WATCHMAN DEVICE PROCEDURE EACH "$28,112.00 " 360 "$19,678.40 " "$14,056.00 " "$22,489.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48106223 CARDIAC CATH CLOSURE DEV VASC LVL 0 EACH C1760 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106231 CARDIAC CATH CLOSURE DEV VASC LVL 1 EACH C1760 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106322 CARDIAC CATH CLOSURE DEV VASC LVL 10 EACH C1760 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106249 CARDIAC CATH CLOSURE DEV VASC LVL 2 EACH C1760 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106256 CARDIAC CATH CLOSURE DEV VASC LVL 3 EACH C1760 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106264 CARDIAC CATH CLOSURE DEV VASC LVL 4 EACH C1760 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106272 CARDIAC CATH CLOSURE DEV VASC LVL 5 EACH C1760 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106280 CARDIAC CATH CLOSURE DEV VASC LVL 6 EACH C1760 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106298 CARDIAC CATH CLOSURE DEV VASC LVL 7 EACH C1760 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106306 CARDIAC CATH CLOSURE DEV VASC LVL 8 EACH C1760 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106314 CARDIAC CATH CLOSURE DEV VASC LVL 9 EACH C1760 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104491 CARDIAC CATH CLOSURE OF SEPTAL DEFECT EACH "$40,049.00 " 481 "$28,034.30 " "$20,024.50 " "$32,039.20 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48190623 CARDIAC CATH CONFIRM AF IC MONIT ILR-DM2102 EACH C1764 "$7,500.00 " 278 "$5,250.00 " "$3,750.00 " "$6,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191191 CARDIAC CATH CONFIRM RX IMP LOOP REC-DM3500 EACH C1764 "$12,500.00 " 278 "$8,750.00 " "$6,250.00 " "$10,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48105472 CARDIAC CATH COOLFLOW PUMP TUBING-CFT001 EACH $258.00 272 $180.60 $129.00 $206.40 65% 80% 50% 50% 65% 65% 65% 48190169 CARDIAC CATH CPS AIM CATH CANN ALII 65CM EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190128 CARDIAC CATH CPS AIM SL CN AL2 65-DS2N025 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190110 CARDIAC CATH CPS AIM SL CN CSL 65-DS2N024 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190011 CARDIAC CATH CPS AIM SL ICS 90 59CM-DS2N022 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190003 CARDIAC CATH CPS AIM SL ICS 90 65CM-DS2N022 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110514 CARDIAC CATH CPS AIM SL ICS ACUT 59-DS2N021 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110506 CARDIAC CATH CPS AIM SL ICS ACUT 65-DS2N021 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190102 CARDIAC CATH CPS AIM SL ICS OBT 59-DS2N023 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190094 CARDIAC CATH CPS AIM SL ICS OBT 65-DS2N023 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110498 CARDIAC CATH CPS AIM SL VLVE BYPASS-DS2A002 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110480 CARDIAC CATH CPS AIM UICC CSL 65-DS2N029-65 EACH C1894 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190086 CARDIAC CATH CPS AIM UICS 90 59-DS2N027-59 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190078 CARDIAC CATH CPS AIM UICS 90 65-DS2N027-65 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190060 CARDIAC CATH CPS AIM UICS AC 65-DS2N026-65 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190052 CARDIAC CATH CPS AIM UICS AC59C-DS2N026-59 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110472 CARDIAC CATH CPS AIM UICS OBT 59-DS2N028-59 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110464 CARDIAC CATH CPS AIM UICS OBT 65-DS2N028-65 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110332 CARDIAC CATH CPS COURIER GW FIRM-DS2G003 EACH C1769 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110274 CARDIAC CATH CPS COURIER GW MEDIUM-DS2G002 EACH C1769 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110324 CARDIAC CATH CPS COURIER GW SOFT-DS2G001 EACH C1769 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110266 CARDIAC CATH CPS COURIER GW X FIRM-DS2G004 EACH C1769 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190243 CARDIAC CATH CPS DSOC 115? 47CM-DS2C002 EACH C1887 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190235 CARDIAC CATH CPS DSOC 115? 54CM-DS2C012 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190227 CARDIAC CATH CPS DSOC 135? 47CM-DS2C003 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190219 CARDIAC CATH CPS DSOC 135? 54CM-DS2C013 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190151 CARDIAC CATH CPS DSOC RIGHT 47CM-DS2C006 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110456 CARDIAC CATH CPS DSOC STRAIGHT 47CM-DS2C001 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110449 CARDIAC CATH CPS DSOC STRAIGHT 54CM-DS2C011 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190201 CARDIAC CATH CPS DSOC WIDE 47CM-DS2C004 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190193 CARDIAC CATH CPS DSOC WIDE 54CM-DS2C014 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190144 CARDIAC CATH CPS DSOC X WIDE 47CM-DS2C005 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190136 CARDIAC CATH CPS DSOC X WIDE 54CM-DS2C015 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190292 CARDIAC CATH CPSDUOC 115 47CM-DS2C019 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190284 CARDIAC CATH CPSDUOC 115 54CM-DS2C026 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110431 CARDIAC CATH CPSDUOC 115 S CURVE 47-DS2C024 EACH C1894 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190045 CARDIAC CATH CPSDUOC 115 S CURVE 54DS2C030 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190276 CARDIAC CATH CPSDUOC 135 47CM-DS2C020 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190268 CARDIAC CATH CPSDUOC 135 54CM -DS2C027 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190185 CARDIAC CATH CPSDUOC RIGHT 47CM-DS2C023 EACH C1894 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190037 CARDIAC CATH CPSDUOC STRAIGHT 47CM-DS2C018 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190029 CARDIAC CATH CPSDUOC STRAIGHT 54CM-DS2C025 EACH C1894 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190250 CARDIAC CATH CPSDUOC WIDE 47CM-DS2C021 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190177 CARDIAC CATH CPSDUOC WIDE 54CM -DS2C028 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110423 CARDIAC CATH CPSDUOC XTRA WIDE 47CM-DS2C022 EACH C1894 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110415 CARDIAC CATH CPSDUOC XTRA WIDE 54CM-DS2C029 EACH C1893 "$1,125.00 " 278 $787.50 $562.50 $900.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104814 CARDIAC CATH DEV INTERROG REMOTE 1/2/MLT EACH 93295 $74.00 480 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105415 CARDIAC CATH DIAGNOSTIC CATHETER-F5QAOO5CF EACH $355.00 272 $248.50 $177.50 $284.00 65% 80% 50% 50% 65% 65% 65% 48105407 CARDIAC CATH DIAGNSOTIC CATHETER-F5CQF252RT EACH $903.00 272 $632.10 $451.50 $722.40 65% 80% 50% 50% 65% 65% 65% 48191092 CARDIAC CATH DURATA DC DF1 DEFIB LD-7120/52 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191084 CARDIAC CATH DURATA DC DF1 DEFIB LD-7120/58 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191076 CARDIAC CATH DURATA DC DF1 DEFIB LD-7120/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191068 CARDIAC CATH DURATA DC DF1 DEFIB LD-7121/60 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191050 CARDIAC CATH DURATA DC DF1 DEFIB LD-7121/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191043 CARDIAC CATH DURATA DC DF1 DEFIB LD-7121/75 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191035 CARDIAC CATH DURATA DC DF1 DEFIB LD-7170/60 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191027 CARDIAC CATH DURATA DC DF1 DEFIB LD-7170/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191019 CARDIAC CATH DURATA DC DF1 DEFIB LD-7171/60 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191001 CARDIAC CATH DURATA DC DF1 DEFIB LD-7171/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190995 CARDIAC CATH DURATA DC DF1 DEFIB LD-7171/75 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190987 CARDIAC CATH DURATA DC DF4 DEFB LD-7120Q/52 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190979 CARDIAC CATH DURATA DC DF4 DEFB LD-7120Q/58 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190961 CARDIAC CATH DURATA DC DF4 DEFB LD-7120Q/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190953 CARDIAC CATH DURATA DC DF4 DEFB LD-7121Q/58 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190946 CARDIAC CATH DURATA DC DF4 DEFB LD-7121Q/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190938 CARDIAC CATH DURATA DC DF4 DEFB LD-7170Q/58 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190920 CARDIAC CATH DURATA DC DF4 DEFB LD-7170Q/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197156 CARDIAC CATH DURATA DC DF4 DEFB LD-7171Q/52 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190912 CARDIAC CATH DURATA DC DF4 DEFB LD-7171Q/58 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190904 CARDIAC CATH DURATA DC DF4 DEFB LD-7171Q/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191134 CARDIAC CATH DURATA SCDF1 DEFIB LD-7122/52 EACH C1777 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191126 CARDIAC CATH DURATA SCDF1 DEFIB LD-7122/58 EACH C1777 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191118 CARDIAC CATH DURATA SCDF1 DEFIB LD-7122/65 EACH C1777 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191100 CARDIAC CATH DURATA SCDF1 DEFIB LD-7122/75 EACH C1777 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190896 CARDIAC CATH DURATA SCDF4 DEFIB LD-7122Q/52 EACH C1777 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190888 CARDIAC CATH DURATA SCDF4 DEFIB LD-7122Q/58 EACH C1777 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190870 CARDIAC CATH DURATA SCDF4 DEFIB LD-7122Q/65 EACH C1777 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193189 CARDIAC CATH DX CATH-107875S EACH C1730 "$2,008.00 " 278 "$1,405.60 " "$1,004.00 " "$1,606.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192793 CARDIAC CATH DX CATH-1079251S EACH C1730 "$1,075.00 " 278 $752.50 $537.50 $860.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192801 CARDIAC CATH DX CATH-1079254S EACH C1730 "$1,075.00 " 278 $752.50 $537.50 $860.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192983 CARDIAC CATH DX CATH-1079257S EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192553 CARDIAC CATH DX CATH-1085122RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192405 CARDIAC CATH DX CATH-1086259RT EACH C1730 $563.00 278 $394.10 $281.50 $450.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192371 CARDIAC CATH DX CATH-1086577S EACH C1730 $563.00 278 $394.10 $281.50 $450.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192850 CARDIAC CATH DX CATH-1086778S EACH C1730 "$1,285.00 " 278 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192835 CARDIAC CATH DX CATH-1088124S EACH C1730 "$1,150.00 " 278 $805.00 $575.00 $920.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192488 CARDIAC CATH DX CATH-112434RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192496 CARDIAC CATH DX CATH-112436RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192470 CARDIAC CATH DX CATH-112442S EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192462 CARDIAC CATH DX CATH-112449S EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193700 CARDIAC CATH DX CATH-116008RT EACH C1731 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193791 CARDIAC CATH DX CATH-122071S EACH C1731 "$4,000.00 " 278 "$2,800.00 " "$2,000.00 " "$3,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193809 CARDIAC CATH DX CATH-122072S EACH C1731 "$4,000.00 " 278 "$2,800.00 " "$2,000.00 " "$3,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193577 CARDIAC CATH DX CATH-122073S EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193874 CARDIAC CATH DX CATH-123703S EACH C1731 "$5,138.00 " 278 "$3,596.60 " "$2,569.00 " "$4,110.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194989 CARDIAC CATH DX CATH-BD710DF282CT EACH C1733 "$1,713.00 " 278 "$1,199.10 " $856.50 "$1,370.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194997 CARDIAC CATH DX CATH-BD710DF282RTS EACH C1733 "$1,713.00 " 278 "$1,199.10 " $856.50 "$1,370.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193155 CARDIAC CATH DX CATH-BD710FJ282CT EACH C1730 "$1,713.00 " 278 "$1,199.10 " $856.50 "$1,370.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193163 CARDIAC CATH DX CATH-BD710FJ282RTS EACH C1730 "$1,713.00 " 278 "$1,199.10 " $856.50 "$1,370.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192355 CARDIAC CATH DX CATH-D1085412 EACH C1730 $550.00 278 $385.00 $275.00 $440.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192363 CARDIAC CATH DX CATH-D1085413 EACH C1730 $550.00 278 $385.00 $275.00 $440.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192439 CARDIAC CATH DX CATH-D1085414 EACH C1730 $613.00 278 $429.10 $306.50 $490.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192504 CARDIAC CATH DX CATH-D1086784 EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196315 CARDIAC CATH DX CATH-D117136 EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48194138 CARDIAC CATH DX CATH-D128201 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194146 CARDIAC CATH DX CATH-D128202 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196331 CARDIAC CATH DX CATH-D128203 EACH "$5,700.00 " 272 "$3,990.00 " "$2,850.00 " "$4,560.00 " 65% 80% 50% 50% 65% 65% 65% 48194153 CARDIAC CATH DX CATH-D128204 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193890 CARDIAC CATH DX CATH-D128205 EACH C1731 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194161 CARDIAC CATH DX CATH-D128206 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194179 CARDIAC CATH DX CATH-D128207 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194229 CARDIAC CATH DX CATH-D128208 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194187 CARDIAC CATH DX CATH-D128209 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194195 CARDIAC CATH DX CATH-D128210 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194203 CARDIAC CATH DX CATH-D128211 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194211 CARDIAC CATH DX CATH-D128212 EACH C1732 "$5,700.00 " 278 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193981 CARDIAC CATH DX CATH-D131209S EACH C1732 "$4,148.00 " 278 "$2,903.60 " "$2,074.00 " "$3,318.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194104 CARDIAC CATH DX CATH-D134301 EACH C1732 "$5,138.00 " 278 "$3,596.60 " "$2,569.00 " "$4,110.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194096 CARDIAC CATH DX CATH-D134302 EACH C1732 "$5,138.00 " 278 "$3,596.60 " "$2,569.00 " "$4,110.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193957 CARDIAC CATH DX CATH-D134901 EACH C1732 "$4,148.00 " 278 "$2,903.60 " "$2,074.00 " "$3,318.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194047 CARDIAC CATH DX CATH-D134902 EACH C1732 "$4,710.00 " 278 "$3,297.00 " "$2,355.00 " "$3,768.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193965 CARDIAC CATH DX CATH-D134903 EACH C1732 "$4,148.00 " 278 "$2,903.60 " "$2,074.00 " "$3,318.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194039 CARDIAC CATH DX CATH-D134904 EACH C1732 "$4,710.00 " 278 "$3,297.00 " "$2,355.00 " "$3,768.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193973 CARDIAC CATH DX CATH-D134905 EACH C1732 "$4,148.00 " 278 "$2,903.60 " "$2,074.00 " "$3,318.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194021 CARDIAC CATH DX CATH-D134906 EACH C1732 "$4,710.00 " 278 "$3,297.00 " "$2,355.00 " "$3,768.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196323 CARDIAC CATH DX CATH-D134909 EACH "$4,148.00 " 272 "$2,903.60 " "$2,074.00 " "$3,318.40 " 65% 80% 50% 50% 65% 65% 65% 48193916 CARDIAC CATH DX CATH-D135303 EACH C1732 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193924 CARDIAC CATH DX CATH-D135304 EACH C1732 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192975 CARDIAC CATH DX CATH-D135305 EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193585 CARDIAC CATH DX CATH-D139801 EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192769 CARDIAC CATH DX CATH-D4S04DR005RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192777 CARDIAC CATH DX CATH-D4S04FR005RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193122 CARDIAC CATH DX CATH-D4S10PR282RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192827 CARDIAC CATH DX CATH-D505AR005RT EACH C1730 "$1,075.00 " 278 $752.50 $537.50 $860.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192819 CARDIAC CATH DX CATH-D505FR005RT EACH C1730 "$1,075.00 " 278 $752.50 $537.50 $860.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193205 CARDIAC CATH DX CATH-D508D005RT EACH C1730 "$2,008.00 " 278 "$1,405.60 " "$1,004.00 " "$1,606.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192926 CARDIAC CATH DX CATH-D508DP10RT EACH C1730 "$1,418.00 " 278 $992.60 $709.00 "$1,134.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193080 CARDIAC CATH DX CATH-D510DRP10RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193072 CARDIAC CATH DX CATH-D510F2250RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193130 CARDIAC CATH DX CATH-D510P2R5155RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193064 CARDIAC CATH DX CATH-D510PR005RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193148 CARDIAC CATH DX CATH-D5S10MZR282RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193114 CARDIAC CATH DX CATH-D5S10PR005RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192868 CARDIAC CATH DX CATH-D5SAL252RT EACH C1730 "$1,285.00 " 278 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192918 CARDIAC CATH DX CATH-D606DR002RT EACH C1730 "$1,285.00 " 278 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192934 CARDIAC CATH DX CATH-D608DR002CT EACH C1730 "$1,418.00 " 278 $992.60 $709.00 "$1,134.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192959 CARDIAC CATH DX CATH-D608DR002RT EACH C1730 "$1,418.00 " 278 $992.60 $709.00 "$1,134.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192967 CARDIAC CATH DX CATH-D608DR252RT EACH C1730 "$1,418.00 " 278 $992.60 $709.00 "$1,134.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193098 CARDIAC CATH DX CATH-D610DR002RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193692 CARDIAC CATH DX CATH-D610DR005RT EACH C1731 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193015 CARDIAC CATH DX CATH-D610DR252RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192991 CARDIAC CATH DX CATH-D610DRP10CT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193056 CARDIAC CATH DX CATH-D610DRP10RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193031 CARDIAC CATH DX CATH-D610FR005RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193023 CARDIAC CATH DX CATH-D610FR252RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193106 CARDIAC CATH DX CATH-D6A10DRP10RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192660 CARDIAC CATH DX CATH-D6DR005CT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192736 CARDIAC CATH DX CATH-D6DR005RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192702 CARDIAC CATH DX CATH-D6DR010RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192652 CARDIAC CATH DX CATH-D6DR252CT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192694 CARDIAC CATH DX CATH-D6DR252RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192744 CARDIAC CATH DX CATH-D6FR252RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193650 CARDIAC CATH DX CATH-D6R20P12RT EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193213 CARDIAC CATH DX CATH-D6S08DRPRYRT EACH C1730 "$2,008.00 " 278 "$1,405.60 " "$1,004.00 " "$1,606.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192785 CARDIAC CATH DX CATH-D6S270L252RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193742 CARDIAC CATH DX CATH-D6T20282RT EACH C1731 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192900 CARDIAC CATH DX CATH-D706DR002RT EACH C1730 "$1,285.00 " 278 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193221 CARDIAC CATH DX CATH-D708DL002RT EACH C1730 "$2,435.00 " 278 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192942 CARDIAC CATH DX CATH-D708DR002RT EACH C1730 "$1,418.00 " 278 $992.60 $709.00 "$1,134.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193197 CARDIAC CATH DX CATH-D708RHISRT EACH C1730 "$2,008.00 " 278 "$1,405.60 " "$1,004.00 " "$1,606.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193007 CARDIAC CATH DX CATH-D710DRP10CT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193049 CARDIAC CATH DX CATH-D710DRP10RT EACH C1730 "$1,503.00 " 278 "$1,052.10 " $751.50 "$1,202.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193718 CARDIAC CATH DX CATH-D728260RT EACH C1731 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193668 CARDIAC CATH DX CATH-D7A20131RT EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192686 CARDIAC CATH DX CATH-D7DR005RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192728 CARDIAC CATH DX CATH-D7DR010RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192678 CARDIAC CATH DX CATH-D7DR252CT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192710 CARDIAC CATH DX CATH-D7DR252RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192751 CARDIAC CATH DX CATH-D7FR252RT EACH C1730 $990.00 278 $693.00 $495.00 $792.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193619 CARDIAC CATH DX CATH-D7L1012RT EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193643 CARDIAC CATH DX CATH-D7L1015CT EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193593 CARDIAC CATH DX CATH-D7L1015RT EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193635 CARDIAC CATH DX CATH-D7L1020CT EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193601 CARDIAC CATH DX CATH-D7L1020RT EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193684 CARDIAC CATH DX CATH-D7L102515RT EACH C1730 "$5,138.00 " 278 "$3,596.60 " "$2,569.00 " "$4,110.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193627 CARDIAC CATH DX CATH-D7L1025RT EACH C1730 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193866 CARDIAC CATH DX CATH-D7L2015CT EACH C1731 "$4,000.00 " 278 "$2,800.00 " "$2,000.00 " "$3,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193825 CARDIAC CATH DX CATH-D7L2015RT EACH C1731 "$4,000.00 " 278 "$2,800.00 " "$2,000.00 " "$3,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193858 CARDIAC CATH DX CATH-D7L2020CT EACH C1731 "$4,000.00 " 278 "$2,800.00 " "$2,000.00 " "$3,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193833 CARDIAC CATH DX CATH-D7L2020RT EACH C1731 "$4,000.00 " 278 "$2,800.00 " "$2,000.00 " "$3,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193882 CARDIAC CATH DX CATH-D7L202515RT EACH C1731 "$5,138.00 " 278 "$3,596.60 " "$2,569.00 " "$4,110.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193817 CARDIAC CATH DX CATH-D7L2025RT EACH C1731 "$4,000.00 " 278 "$2,800.00 " "$2,000.00 " "$3,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193841 CARDIAC CATH DX CATH-D7L2030RT EACH C1731 "$4,000.00 " 278 "$2,800.00 " "$2,000.00 " "$3,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193767 CARDIAC CATH DX CATH-D7R20LCSRT EACH C1731 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193775 CARDIAC CATH DX CATH-D7R20P14CT EACH C1731 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193759 CARDIAC CATH DX CATH-D7R20P14RT EACH C1731 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193783 CARDIAC CATH DX CATH-D7T20282CT EACH C1731 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193726 CARDIAC CATH DX CATH-D7T20282RT EACH C1731 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193734 CARDIAC CATH DX CATH-D7T20P15RT EACH C1731 "$3,425.00 " 278 "$2,397.50 " "$1,712.50 " "$2,740.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193999 CARDIAC CATH DX CATH-DLN1215CT EACH C1732 "$4,148.00 " 278 "$2,903.60 " "$2,074.00 " "$3,318.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194005 CARDIAC CATH DX CATH-DLN1220CT EACH C1732 "$4,148.00 " 278 "$2,903.60 " "$2,074.00 " "$3,318.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194013 CARDIAC CATH DX CATH-DLN1225CT EACH C1732 "$4,148.00 " 278 "$2,903.60 " "$2,074.00 " "$3,318.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194070 CARDIAC CATH DX CATH-DLN2215CT EACH C1732 "$4,710.00 " 278 "$3,297.00 " "$2,355.00 " "$3,768.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194062 CARDIAC CATH DX CATH-DLN2220CT EACH C1732 "$4,710.00 " 278 "$3,297.00 " "$2,355.00 " "$3,768.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194054 CARDIAC CATH DX CATH-DLN2225CT EACH C1732 "$4,710.00 " 278 "$3,297.00 " "$2,355.00 " "$3,768.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192017 CARDIAC CATH DX CATH-F4QA005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192546 CARDIAC CATH DX CATH-F4QD005RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192009 CARDIAC CATH DX CATH-F4QF005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191993 CARDIAC CATH DX CATH-F4QH005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192843 CARDIAC CATH DX CATH-F4SHH252RT EACH C1730 "$1,150.00 " 278 $805.00 $575.00 $920.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192587 CARDIAC CATH DX CATH-F5ADP282CT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192645 CARDIAC CATH DX CATH-F5ADP282RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192629 CARDIAC CATH DX CATH-F5ADPP10RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192298 CARDIAC CATH DX CATH-F5CQA005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192306 CARDIAC CATH DX CATH-F5CQA252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192314 CARDIAC CATH DX CATH-F5CQD005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192603 CARDIAC CATH DX CATH-F5CQD252RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192280 CARDIAC CATH DX CATH-F5CQF005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191894 CARDIAC CATH DX CATH-F5QA002RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191860 CARDIAC CATH DX CATH-F5QA005CT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191910 CARDIAC CATH DX CATH-F5QA005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191902 CARDIAC CATH DX CATH-F5QA252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191928 CARDIAC CATH DX CATH-F5QD005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191944 CARDIAC CATH DX CATH-F5QD010RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191936 CARDIAC CATH DX CATH-F5QD252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191837 CARDIAC CATH DX CATH-F5QF005CT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191969 CARDIAC CATH DX CATH-F5QF005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191977 CARDIAC CATH DX CATH-F5QF010RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191951 CARDIAC CATH DX CATH-F5QF252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191985 CARDIAC CATH DX CATH-F5QL005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191886 CARDIAC CATH DX CATH-F5QL010ST EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192223 CARDIAC CATH DX CATH-F5QRA005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192249 CARDIAC CATH DX CATH-F5QRA252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192231 CARDIAC CATH DX CATH-F5QRF005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192256 CARDIAC CATH DX CATH-F5QRF252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192611 CARDIAC CATH DX CATH-F5SQA252RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192322 CARDIAC CATH DX CATH-F65QA005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192637 CARDIAC CATH DX CATH-F6ADP282RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192264 CARDIAC CATH DX CATH-F6CQA005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192595 CARDIAC CATH DX CATH-F6CQA252RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192330 CARDIAC CATH DX CATH-F6CQF005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192348 CARDIAC CATH DX CATH-F6CQF010RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192272 CARDIAC CATH DX CATH-F6CQF252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192579 CARDIAC CATH DX CATH-F6DF252RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192561 CARDIAC CATH DX CATH-F6DG252RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192389 CARDIAC CATH DX CATH-F6HA002RT EACH C1730 $563.00 278 $394.10 $281.50 $450.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192421 CARDIAC CATH DX CATH-F6HF002RT EACH C1730 $563.00 278 $394.10 $281.50 $450.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192397 CARDIAC CATH DX CATH-F6HF005RT EACH C1730 $563.00 278 $394.10 $281.50 $450.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192413 CARDIAC CATH DX CATH-F6HF010RT EACH C1730 $563.00 278 $394.10 $281.50 $450.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192447 CARDIAC CATH DX CATH-F6OA002RT EACH C1730 $723.00 278 $506.10 $361.50 $578.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192454 CARDIAC CATH DX CATH-F6OF002RT EACH C1730 $723.00 278 $506.10 $361.50 $578.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192132 CARDIAC CATH DX CATH-F6QA002RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191852 CARDIAC CATH DX CATH-F6QA005CT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192157 CARDIAC CATH DX CATH-F6QA005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192074 CARDIAC CATH DX CATH-F6QA010RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192140 CARDIAC CATH DX CATH-F6QA252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192082 CARDIAC CATH DX CATH-F6QD002RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192108 CARDIAC CATH DX CATH-F6QD005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192116 CARDIAC CATH DX CATH-F6QD010RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192090 CARDIAC CATH DX CATH-F6QD252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192124 CARDIAC CATH DX CATH-F6QF002RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191845 CARDIAC CATH DX CATH-F6QF005CT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192033 CARDIAC CATH DX CATH-F6QF005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192041 CARDIAC CATH DX CATH-F6QF010RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191878 CARDIAC CATH DX CATH-F6QF010ST EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192025 CARDIAC CATH DX CATH-F6QF252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192512 CARDIAC CATH DX CATH-F6QG010RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192058 CARDIAC CATH DX CATH-F6QK002RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192066 CARDIAC CATH DX CATH-F6QL005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192538 CARDIAC CATH DX CATH-F6QL010RT EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192520 CARDIAC CATH DX CATH-F6QL010ST EACH C1730 $858.00 278 $600.60 $429.00 $686.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192165 CARDIAC CATH DX CATH-F6QRA005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192215 CARDIAC CATH DX CATH-F6QRA010RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192181 CARDIAC CATH DX CATH-F6QRA252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192173 CARDIAC CATH DX CATH-F6QRF005RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192207 CARDIAC CATH DX CATH-F6QRF010RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192199 CARDIAC CATH DX CATH-F6QRF252RT EACH C1730 $355.00 278 $248.50 $177.50 $284.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192892 CARDIAC CATH DX CATH-F7LADPP10RT EACH C1730 "$1,285.00 " 278 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192876 CARDIAC CATH DX CATH-F7LDG005RT EACH C1730 "$1,285.00 " 278 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48192884 CARDIAC CATH DX CATH-F7LDG252RT EACH C1730 "$1,285.00 " 278 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194112 CARDIAC CATH DX CATH-LN122515CT EACH C1732 "$5,138.00 " 278 "$3,596.60 " "$2,569.00 " "$4,110.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48194120 CARDIAC CATH DX CATH-LN222515CT EACH C1732 "$5,138.00 " 278 "$3,596.60 " "$2,569.00 " "$4,110.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193502 CARDIAC CATH DX CATH-OD73X4D010FS EACH C1730 "$2,570.00 " 278 "$1,799.00 " "$1,285.00 " "$2,056.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193510 CARDIAC CATH DX CATH-OD78X2D005FS EACH C1730 "$2,570.00 " 278 "$1,799.00 " "$1,285.00 " "$2,056.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193171 CARDIAC CATH DX CATH-OF63X4C010FS EACH C1730 "$1,848.00 " 278 "$1,293.60 " $924.00 "$1,478.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193932 CARDIAC CATH DX CATH-R7D282CT EACH C1732 "$3,290.00 " 278 "$2,303.00 " "$1,645.00 " "$2,632.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48193940 CARDIAC CATH DX CATH-R7F282CT EACH C1732 "$3,290.00 " 278 "$2,303.00 " "$1,645.00 " "$2,632.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191365 CARDIAC CATH ELIPSE DC DF1 ICD M CD2411-36C EACH C1785 "$36,250.00 " 278 "$25,375.00 " "$18,125.00 " "$29,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191282 CARDIAC CATH ELIPSE DC DF1 ICD-CD2411-36C EACH C1721 "$31,250.00 " 278 "$21,875.00 " "$15,625.00 " "$25,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191381 CARDIAC CATH ELIPSE DC DF1 ICD-CD2411-36C EACH C1785 "$36,250.00 " 278 "$25,375.00 " "$18,125.00 " "$29,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191456 CARDIAC CATH ELIPSE DC DF4 ICD M-CD2411-36Q EACH C1785 "$40,000.00 " 278 "$28,000.00 " "$20,000.00 " "$32,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191340 CARDIAC CATH ELIPSE DC DF4 ICD-CD2411-36Q EACH C1721 "$35,000.00 " 278 "$24,500.00 " "$17,500.00 " "$28,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191472 CARDIAC CATH ELIPSE DC DF4 ICD-CD2411-36Q EACH C1785 "$40,000.00 " 278 "$28,000.00 " "$20,000.00 " "$32,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191316 CARDIAC CATH "ELIPSE DF1 ICD SYS, MERLIN PKG" EACH C1785 "$33,750.00 " 278 "$23,625.00 " "$16,875.00 " "$27,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191415 CARDIAC CATH "ELIPSE DF4 ICD SYS, MERLIN PKG" EACH C1785 "$37,500.00 " 278 "$26,250.00 " "$18,750.00 " "$30,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191266 CARDIAC CATH ELIPSE SC DF1 ICD-CD1411-36C EACH C1722 "$28,750.00 " 278 "$20,125.00 " "$14,375.00 " "$23,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191308 CARDIAC CATH ELIPSE SC DF1 ICD-CD1411-36C S EACH C1785 "$33,750.00 " 278 "$23,625.00 " "$16,875.00 " "$27,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191290 CARDIAC CATH ELIPSE SC DF4 ICD-CD1411-36Q EACH C1722 "$32,500.00 " 278 "$22,750.00 " "$16,250.00 " "$26,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191407 CARDIAC CATH ELIPSE SC DF4 ICD-CD1411-36Q S EACH C1785 "$37,500.00 " 278 "$26,250.00 " "$18,750.00 " "$30,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190755 CARDIAC CATH ENDURIT SR PM M-PM1160 SYSCELL EACH C1786 "$8,750.00 " 278 "$6,125.00 " "$4,375.00 " "$7,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190680 CARDIAC CATH ENDURITY DR PACEMAKER-PM2160 EACH C1785 "$8,000.00 " 278 "$5,600.00 " "$4,000.00 " "$6,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191142 CARDIAC CATH ENDURITY DR PM SYST-PM2160 SYS EACH C1785 "$9,750.00 " 278 "$6,825.00 " "$4,875.00 " "$7,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190649 CARDIAC CATH ENDURITY SR PACEMAKER-PM1160 EACH C1786 "$7,750.00 " 278 "$5,425.00 " "$3,875.00 " "$6,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190763 CARDIAC CATH ENDURITY SR PM SYST-PM1160 EACH C1786 "$8,750.00 " 278 "$6,125.00 " "$4,375.00 " "$7,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48105506 CARDIAC CATH EP PERIPHERAL VENOGRAM EACH $510.00 481 $357.00 $255.00 $408.00 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105019 CARDIAC CATH EPS-ABLATION EACH "$12,743.00 " 480 "$8,920.10 " "$6,371.50 " "$10,194.40 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105027 CARDIAC CATH EPS-EP STUDIES EACH "$12,743.00 " 480 "$8,920.10 " "$6,371.50 " "$10,194.40 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105068 CARDIAC CATH EPS-EVALUATION/TESTING EACH $578.00 480 $404.60 $289.00 $462.40 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105084 CARDIAC CATH EPS-HEMATOMA EVACUATION EACH "$3,440.00 " 480 "$2,408.00 " "$1,720.00 " "$2,752.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105001 CARDIAC CATH EPS-HIS RECORDING/MAPPING EACH "$12,743.00 " 480 "$8,920.10 " "$6,371.50 " "$10,194.40 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105142 CARDIAC CATH EPS-ILR IMPLANTATION/REMOVE EACH "$18,510.00 " 480 "$12,957.00 " "$9,255.00 " "$14,808.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105043 CARDIAC CATH EPS-IMPLANT CRT EACH "$77,641.00 " 480 "$54,348.70 " "$38,820.50 " "$62,112.80 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105092 CARDIAC CATH EPS-IMPLANT ICD EACH "$54,990.00 " 480 "$38,493.00 " "$27,495.00 " "$43,992.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105076 CARDIAC CATH EPS-IMPLANT PACEMAKER EACH "$18,511.00 " 480 "$12,957.70 " "$9,255.50 " "$14,808.80 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105175 CARDIAC CATH EPS-IMPLANT PM/ICD COMBO EACH "$76,641.00 " 481 "$53,648.70 " "$38,320.50 " "$61,312.80 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105050 CARDIAC CATH EPS-NEW ICD ELECTROD ONLY EACH "$18,510.00 " 480 "$12,957.00 " "$9,255.00 " "$14,808.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105241 CARDIAC CATH EPS-PERIPHERAL VENOGRAM EACH "$1,577.00 " 481 "$1,103.90 " $788.50 "$1,261.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105217 CARDIAC CATH EPS-REMOVE CRT EACH "$56,990.00 " 481 "$39,893.00 " "$28,495.00 " "$45,592.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105167 CARDIAC CATH EPS-REMOVE ICD EACH "$54,990.00 " 481 "$38,493.00 " "$27,495.00 " "$43,992.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105035 CARDIAC CATH EPS-REMOVE PACEMAKER EACH "$18,511.00 " 480 "$12,957.70 " "$9,255.50 " "$14,808.80 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105183 CARDIAC CATH EPS-REMOVE PM/ICD COMBO EACH "$55,990.00 " 481 "$39,193.00 " "$27,995.00 " "$44,792.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105225 CARDIAC CATH EPS-REPLACE CRT EACH "$77,441.00 " 481 "$54,208.70 " "$38,720.50 " "$61,952.80 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105134 CARDIAC CATH EPS-REPLACE ICD EACH "$54,990.00 " 480 "$38,493.00 " "$27,495.00 " "$43,992.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105159 CARDIAC CATH EPS-REPLACE PACEMAKER EACH "$24,699.00 " 481 "$17,289.30 " "$12,349.50 " "$19,759.20 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105191 CARDIAC CATH EPS-REPLACE PM/ICD COMBO EACH "$76,441.00 " 481 "$53,508.70 " "$38,220.50 " "$61,152.80 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105209 CARDIAC CATH EPS-REVISE/REPOSITION CRT EACH "$9,828.00 " 481 "$6,879.60 " "$4,914.00 " "$7,862.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105118 CARDIAC CATH EPS-REVISE/REPOSITION ICD EACH "$7,828.00 " 480 "$5,479.60 " "$3,914.00 " "$6,262.40 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48105233 CARDIAC CATH EPS-REVISE/REPOSITION PM EACH "$7,828.00 " 481 "$5,479.60 " "$3,914.00 " "$6,262.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105126 CARDIAC CATH EPS-REVISE/REPOSITION PM/ICD EACH "$8,828.00 " 480 "$6,179.60 " "$4,414.00 " "$7,062.40 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104798 CARDIAC CATH EVAL PHONE RHYTHM STRIP EACH 93293 $94.00 732 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48110019 CARDIAC CATH FIRM STYLETS-4091/100 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110126 CARDIAC CATH FIRM STYLETS-4091/40 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110118 CARDIAC CATH FIRM STYLETS-4091/46 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110100 CARDIAC CATH FIRM STYLETS-4091/52 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110092 CARDIAC CATH FIRM STYLETS-4091/58 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110084 CARDIAC CATH FIRM STYLETS-4091/65 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110076 CARDIAC CATH FIRM STYLETS-4091/85 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48191423 CARDIAC CATH FORT DC DF1 ICD MER-CD2357-40C EACH C1785 "$38,750.00 " 278 "$27,125.00 " "$19,375.00 " "$31,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191324 CARDIAC CATH FORTIFY DC DF1 ICD-CD2357-40C EACH C1721 "$33,750.00 " 278 "$23,625.00 " "$16,875.00 " "$27,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191431 CARDIAC CATH FORTIFY DC DF1 ICD-CD2357-40C EACH C1785 "$38,750.00 " 278 "$27,125.00 " "$19,375.00 " "$31,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191480 CARDIAC CATH FORTIFY DC DF4 ICD MERL-CD2357 EACH C1785 "$42,500.00 " 278 "$29,750.00 " "$21,250.00 " "$34,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191399 CARDIAC CATH FORTIFY DC DF4 ICD-CD2357-40Q EACH C1721 "$37,500.00 " 278 "$26,250.00 " "$18,750.00 " "$30,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191498 CARDIAC CATH FORTIFY DC DF4 ICD-CD2357-40Q EACH C1785 "$42,500.00 " 278 "$29,750.00 " "$21,250.00 " "$34,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191274 CARDIAC CATH FORTIFY SC DF1 ICD-CD1357-40C EACH C1722 "$31,250.00 " 278 "$21,875.00 " "$15,625.00 " "$25,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191373 CARDIAC CATH FORTIFY SC DF1 ICD-CD1357-40C EACH C1785 "$36,250.00 " 278 "$25,375.00 " "$18,125.00 " "$29,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191332 CARDIAC CATH FORTIFY SC DF4 ICD-CD1357-40Q EACH C1722 "$35,000.00 " 278 "$24,500.00 " "$17,500.00 " "$28,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191464 CARDIAC CATH FORTIFY SC DF4 ICD-CD1357-40Q EACH C1785 "$40,000.00 " 278 "$28,000.00 " "$20,000.00 " "$32,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191357 CARDIAC CATH FORTIFY SGL DF1 ICD SYS MERLIN EACH C1785 "$36,250.00 " 278 "$25,375.00 " "$18,125.00 " "$29,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191449 CARDIAC CATH FORTIFY SGL DF4 ICD SYS MERLIN EACH C1785 "$40,000.00 " 278 "$28,000.00 " "$20,000.00 " "$32,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197198 CARDIAC CATH GALLANT-DR ICD-CDDRA500Q EACH C1721 "$24,624.00 " 275 "$17,236.80 " "$12,312.00 " "$19,699.20 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197214 CARDIAC CATH GALLANT-HF CRTD-CDHFA500Q EACH C1882 "$35,079.00 " 275 "$24,555.30 " "$17,539.50 " "$28,063.20 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197206 CARDIAC CATH GALLANT-VR ICD-CDVRA500Q EACH C1722 "$22,983.00 " 275 "$16,088.10 " "$11,491.50 " "$18,386.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106330 CARDIAC CATH GRAFT VASCULAR LVL 0 EACH C1768 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106348 CARDIAC CATH GRAFT VASCULAR LVL 1 EACH C1768 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106439 CARDIAC CATH GRAFT VASCULAR LVL 10 EACH C1768 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106355 CARDIAC CATH GRAFT VASCULAR LVL 2 EACH C1768 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106363 CARDIAC CATH GRAFT VASCULAR LVL 3 EACH C1768 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106371 CARDIAC CATH GRAFT VASCULAR LVL 4 EACH C1768 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106389 CARDIAC CATH GRAFT VASCULAR LVL 5 EACH C1768 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106397 CARDIAC CATH GRAFT VASCULAR LVL 6 EACH C1768 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106405 CARDIAC CATH GRAFT VASCULAR LVL 7 EACH C1768 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106413 CARDIAC CATH GRAFT VASCULAR LVL 8 EACH C1768 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106421 CARDIAC CATH GRAFT VASCULAR LVL 9 EACH C1768 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106447 CARDIAC CATH GUIDEWIRE LVL 0 EACH C1769 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106454 CARDIAC CATH GUIDEWIRE LVL 1 EACH C1769 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106546 CARDIAC CATH GUIDEWIRE LVL 10 EACH C1769 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106462 CARDIAC CATH GUIDEWIRE LVL 2 EACH C1769 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106470 CARDIAC CATH GUIDEWIRE LVL 3 EACH C1769 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106488 CARDIAC CATH GUIDEWIRE LVL 4 EACH C1769 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106496 CARDIAC CATH GUIDEWIRE LVL 5 EACH C1769 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106504 CARDIAC CATH GUIDEWIRE LVL 6 EACH C1769 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106512 CARDIAC CATH GUIDEWIRE LVL 7 EACH C1769 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106520 CARDIAC CATH GUIDEWIRE LVL 8 EACH C1769 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106538 CARDIAC CATH GUIDEWIRE LVL 9 EACH C1769 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191720 CARDIAC CATH GUIDING SHEATH 63CM 135 DEGREE EACH C1893 $413.00 278 $289.10 $206.50 $330.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191712 CARDIAC CATH GUIDING SHEATH 63CM 37 DEGREE EACH C1893 $413.00 278 $289.10 $206.50 $330.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191704 CARDIAC CATH GUIDING SHEATH 63CM 45 DEGREE EACH C1893 $413.00 278 $289.10 $206.50 $330.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191696 CARDIAC CATH GUIDING SHEATH 63CM 55 DEGREE EACH C1893 $413.00 278 $289.10 $206.50 $330.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191688 CARDIAC CATH GUIDING SHEATH 63CM 90 DEGREE EACH C1893 $413.00 278 $289.10 $206.50 $330.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191670 CARDIAC CATH GUIDING SHEATH 81CM 135 DEGREE EACH C1893 $413.00 278 $289.10 $206.50 $330.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191662 CARDIAC CATH GUIDING SHEATH 81CM 45 DEGREE EACH C1893 $413.00 278 $289.10 $206.50 $330.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191654 CARDIAC CATH GUIDING SHEATH 81CM 55 DEGREE EACH C1893 $413.00 278 $289.10 $206.50 $330.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191647 CARDIAC CATH GUIDING SHEATH 81CM 90 DEGREE EACH C1893 $413.00 278 $289.10 $206.50 $330.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48105423 CARDIAC CATH HALO CATHETER-D6T2028RT EACH "$3,425.00 " 272 "$2,397.50 " "$1,712.50 " "$2,740.00 " 65% 80% 50% 50% 65% 65% 65% 48104632 CARDIAC CATH IABP INSERTION OR REMOVAL EACH "$18,073.00 " 481 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104889 CARDIAC CATH ICM DEVICE EVAL EACH 93290 $94.00 480 $65.80 $47.00 $75.20 65% 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104913 CARDIAC CATH ICM DEVICE INTERROG REMOTE EACH 93297 $74.00 480 $51.80 $37.00 $59.20 65% 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104673 CARDIAC CATH IFR ONLY MULTIPLE VESSELS EACH $512.00 481 $358.40 $256.00 $409.60 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104665 CARDIAC CATH IFR ONLY ONE VESSEL EACH $341.00 481 $238.70 $170.50 $272.80 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104335 CARDIAC CATH IMPLANT CARD RECORDER EACH "$12,712.00 " 481 "$8,898.40 " "$6,356.00 " "$10,169.60 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48197255 CARDIAC CATH INOUE-BALLOON EACH "$6,250.00 " 272 "$4,375.00 " "$3,125.00 " "$5,000.00 " 65% 80% 50% 50% 65% 65% 65% 48105498 CARDIAC CATH INQUIRY DUODECAPOLAR CATHETER EACH $598.00 272 $418.60 $299.00 $478.40 65% 80% 50% 50% 65% 65% 65% 48104780 CARDIAC CATH INTERROG IMPLANT DEFIB DEVICE EACH 93289 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104897 CARDIAC CATH INTERROG IMPLT LOOP RECORDER EACH 93291 $74.00 480 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104772 CARDIAC CATH INTERROG PACER 1-MUL LEAD EACH 93288 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104905 CARDIAC CATH INTERROG WEARABLE DEFIB SYSTEM EACH 93292 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104707 CARDIAC CATH INTERROGATE SUBQ DEFIB EACH 93261 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48107106 CARDIAC CATH INTRODUCER/SHEATH LVL 0 EACH C1894 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107114 CARDIAC CATH INTRODUCER/SHEATH LVL 1 EACH C1894 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107205 CARDIAC CATH INTRODUCER/SHEATH LVL 10 EACH C1894 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107122 CARDIAC CATH INTRODUCER/SHEATH LVL 2 EACH C1894 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107130 CARDIAC CATH INTRODUCER/SHEATH LVL 3 EACH C1894 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107148 CARDIAC CATH INTRODUCER/SHEATH LVL 4 EACH C1894 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107155 CARDIAC CATH INTRODUCER/SHEATH LVL 5 EACH C1894 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107163 CARDIAC CATH INTRODUCER/SHEATH LVL 6 EACH C1894 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107171 CARDIAC CATH INTRODUCER/SHEATH LVL 7 EACH C1894 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107189 CARDIAC CATH INTRODUCER/SHEATH LVL 8 EACH C1894 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107197 CARDIAC CATH INTRODUCER/SHEATH LVL 9 EACH C1894 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110407 CARDIAC CATH ISOFLEX OPTIM-1944/46 EACH C1898 "$1,000.00 " 278 $700.00 $500.00 $800.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110399 CARDIAC CATH ISOFLEX OPTIM-1944/52 EACH C1898 "$1,000.00 " 278 $700.00 $500.00 $800.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110381 CARDIAC CATH ISOFLEX OPTIM-1948/46 EACH C1898 "$1,000.00 " 278 $700.00 $500.00 $800.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110373 CARDIAC CATH ISOFLEX OPTIM-1948/52 EACH C1898 "$1,000.00 " 278 $700.00 $500.00 $800.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110365 CARDIAC CATH ISOFLEX OPTIM-1948/58 EACH C1898 "$1,000.00 " 278 $700.00 $500.00 $800.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197149 CARDIAC CATH LARGE CURL SSID-FST-085-02 EACH C1766 "$2,250.00 " 278 "$1,575.00 " "$1,125.00 " "$1,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197164 CARDIAC CATH LARGE CURL SSID-HST-085-20 EACH C1766 "$1,914.00 " 278 "$1,339.80 " $957.00 "$1,531.20 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197131 CARDIAC CATH MEDIUM CURL SSID-FST-085-01 EACH C1766 "$2,250.00 " 278 "$1,575.00 " "$1,125.00 " "$1,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196570 CARDIAC CATH MEDIUM CURL SSID-HST-085-10 EACH C1894 "$1,914.00 " 278 "$1,339.80 " $957.00 "$1,531.20 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106553 CARDIAC CATH MESH LVL 0 EACH C1781 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106561 CARDIAC CATH MESH LVL 1 EACH C1781 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106652 CARDIAC CATH MESH LVL 10 EACH C1781 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106579 CARDIAC CATH MESH LVL 2 EACH C1781 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106587 CARDIAC CATH MESH LVL 3 EACH C1781 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106595 CARDIAC CATH MESH LVL 4 EACH C1781 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106603 CARDIAC CATH MESH LVL 5 EACH C1781 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106611 CARDIAC CATH MESH LVL 6 EACH C1781 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106629 CARDIAC CATH MESH LVL 7 EACH C1781 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106637 CARDIAC CATH MESH LVL 8 EACH C1781 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106645 CARDIAC CATH MESH LVL 9 EACH C1781 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110357 CARDIAC CATH MP EPICARDIAL LD 35 CM-511211 EACH C1898 "$1,000.00 " 278 $700.00 $500.00 $800.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110340 CARDIAC CATH MP EPICARDIAL LD 54 CM-511212 EACH C1898 "$1,000.00 " 278 $700.00 $500.00 $800.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197180 CARDIAC CATH MUSTANG OTW-H74939171120470 EACH C1725 $480.00 278 $336.00 $240.00 $384.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197222 CARDIAC CATH NRG EEPROM HIGH FLOW C1 CURVE EACH "$1,213.00 " 272 $849.10 $606.50 $970.40 65% 80% 50% 50% 65% 65% 65% 48190862 CARDIAC CATH OPT DC DF4 DEFIB LD-LDA220Q/58 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190854 CARDIAC CATH OPT DC DF4 DEFIB LD-LDA220Q/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190847 CARDIAC CATH OPT DC DF4 DEFIB LD-LDA230Q/58 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190839 CARDIAC CATH OPT DC DF4 DEFIB LD-LDA230Q/65 EACH C1895 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190821 CARDIAC CATH OPT SC DF4 DEFIB LD-LDA210Q/58 EACH C1777 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190813 CARDIAC CATH OPT SC DF4 DEFIB LD-LDA210Q/65 EACH C1777 "$9,500.00 " 278 "$6,650.00 " "$4,750.00 " "$7,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104145 CARDIAC CATH PACEMAKER PACK EACH $173.00 272 $121.10 $86.50 $138.40 65% 80% 50% 50% 65% 65% 65% 48104681 CARDIAC CATH PCTA WITH IFR EACH "$7,375.00 " 481 "$5,162.50 " "$3,687.50 " "$5,900.00 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48105399 CARDIAC CATH PENTARAY CABLE EACH "$1,100.00 " 272 $770.00 $550.00 $880.00 65% 80% 50% 50% 65% 65% 65% 48104640 CARDIAC CATH PERCARDIOCENTESIS INITIAL/SUBS EACH "$2,458.00 " 481 "$1,720.60 " "$1,229.00 " "$1,966.40 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104921 CARDIAC CATH PF-ILR DEVICE INTERROG REMOTE EACH 93298 $74.00 480 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48197248 CARDIAC CATH PIGTAIL ANGLE145 EACH $68.00 272 $47.60 $34.00 $54.40 65% 80% 50% 50% 65% 65% 65% 48104822 CARDIAC CATH PM/ICD REMOTE TECH SERV EACH 93296 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104863 CARDIAC CATH PRE/POST PROG EVAL MULTI LEAD EACH 93286 $74.00 480 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104699 CARDIAC CATH PRGRMG DEV EVAL IMPLTBL SYS EACH 93260 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104749 CARDIAC CATH PRGRMG EVAL IMPLANT DFB SGL EACH 93282 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104764 CARDIAC CATH PRGRMG EVL IMPLANT DFB MULT EACH 93284 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104855 CARDIAC CATH PROG EVAL IMPLT LOOP RECORDER EACH 93285 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104715 CARDIAC CATH PROG EVAL PACEMKR 1 LEAD EACH 93279 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104723 CARDIAC CATH PROG EVAL PACEMKR DUAL LEAD EACH 93280 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104731 CARDIAC CATH PROG EVAL PACEMKR MULTI LEAD EACH 93281 $94.00 480 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48191639 CARDIAC CATH PROTRACK PIGTAIL WIRE (175 CM) EACH C1769 $450.00 278 $315.00 $225.00 $360.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191621 CARDIAC CATH PROTRACK PIGTAIL WIRE (230 CM) EACH C1769 $450.00 278 $315.00 $225.00 $360.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104426 CARDIAC CATH PRQ REVASC BYP GRAFT 1 VSL EACH "$26,275.00 " 481 "$18,392.50 " "$13,137.50 " "$21,020.00 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104434 CARDIAC CATH PRQ REVASC BYP GRAFT 2+ VSL EACH "$32,844.00 " 481 "$22,990.80 " "$16,422.00 " "$26,275.20 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104442 CARDIAC CATH PRQ REVASC MI 1 VSL EACH "$26,275.00 " 481 "$18,392.50 " "$13,137.50 " "$21,020.00 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104459 CARDIAC CATH PRQ REVASC MI MULTIPLE VSL EACH "$32,844.00 " 481 "$22,990.80 " "$16,422.00 " "$26,275.20 " 65% 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104558 CARDIAC CATH PTA EACH "$12,712.00 " 360 "$8,898.40 " "$6,356.00 " "$10,169.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48104566 CARDIAC CATH PTA 2+ ARTERIES EACH "$19,068.00 " 360 "$13,347.60 " "$9,534.00 " "$15,254.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48104574 CARDIAC CATH PTA ATHERECTOMY EACH "$26,275.00 " 360 "$18,392.50 " "$13,137.50 " "$21,020.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48104582 CARDIAC CATH PTA ATHERECTOMY W/STENT 2+ EACH "$50,061.00 " 360 "$35,042.70 " "$25,030.50 " "$40,048.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48104590 CARDIAC CATH PTA ATHERECTOMY W/STENT- FIRST EACH "$40,049.00 " 360 "$28,034.30 " "$20,024.50 " "$32,039.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48104608 CARDIAC CATH PTA WITH MULTIPLE STENTS EACH "$32,844.00 " 360 "$22,990.80 " "$16,422.00 " "$26,275.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48104616 CARDIAC CATH PTA WITH STENT EACH "$26,275.00 " 360 "$18,392.50 " "$13,137.50 " "$21,020.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48191605 CARDIAC CATH QA CRT-D SYS MERLIN-CD3369-40C EACH C2621 "$62,500.00 " 278 "$43,750.00 " "$31,250.00 " "$50,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191597 CARDIAC CATH QA CRT-D SYS MERLIN-CD3369-40Q EACH C1882 "$62,500.00 " 278 "$43,750.00 " "$31,250.00 " "$50,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191613 CARDIAC CATH QA CRT-D SYS-CD3369-40C SYS EACH C2621 "$62,500.00 " 278 "$43,750.00 " "$31,250.00 " "$50,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191589 CARDIAC CATH QA CRT-D SYS-CD3369-40Q SYSTEM EACH C1882 "$62,500.00 " 278 "$43,750.00 " "$31,250.00 " "$50,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190524 CARDIAC CATH QF MICRO LF HR PL-1258T/75 EACH C1900 "$5,500.00 " 278 "$3,850.00 " "$2,750.00 " "$4,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190516 CARDIAC CATH QF MICRO LF HR PL-1258T/86 EACH C1900 "$5,500.00 " 278 "$3,850.00 " "$2,750.00 " "$4,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190508 CARDIAC CATH QF MICRO LF HR PL-1258T/92 EACH C1900 "$5,500.00 " 278 "$3,850.00 " "$2,750.00 " "$4,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191530 CARDIAC CATH QUADRA ASSURA CRT-D-CD3369-40C EACH C1882 "$52,500.00 " 278 "$36,750.00 " "$26,250.00 " "$42,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191522 CARDIAC CATH QUADRA ASSURA CRT-D-CD3369-40Q EACH C1882 "$52,500.00 " 278 "$36,750.00 " "$26,250.00 " "$42,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190615 CARDIAC CATH QUARTET LF HR PL-1456Q/75 EACH C1900 "$7,000.00 " 278 "$4,900.00 " "$3,500.00 " "$5,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190607 CARDIAC CATH QUARTET LF HR PL-1456Q/86 EACH C1900 "$7,000.00 " 278 "$4,900.00 " "$3,500.00 " "$5,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190599 CARDIAC CATH QUARTET LF HR PL-1457Q/75 EACH C1900 "$7,000.00 " 278 "$4,900.00 " "$3,500.00 " "$5,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190581 CARDIAC CATH QUARTET LF HR PL-1457Q/86 EACH C1900 "$7,000.00 " 278 "$4,900.00 " "$3,500.00 " "$5,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190573 CARDIAC CATH QUARTET LF HR PL-1458Q/75 EACH C1900 "$7,000.00 " 278 "$4,900.00 " "$3,500.00 " "$5,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190565 CARDIAC CATH QUARTET LF HR PL-1458Q/86 EACH C1900 "$7,000.00 " 278 "$4,900.00 " "$3,500.00 " "$5,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190557 CARDIAC CATH QUARTET LF HR PL-1458Q/92 EACH C1900 "$7,000.00 " 278 "$4,900.00 " "$3,500.00 " "$5,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190540 CARDIAC CATH QUARTET LF HR PL-1458QL/75 EACH C1900 "$7,000.00 " 278 "$4,900.00 " "$3,500.00 " "$5,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190532 CARDIAC CATH QUARTET LF HR PL-1458QL/86 EACH C1900 "$7,000.00 " 278 "$4,900.00 " "$3,500.00 " "$5,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104137 CARDIAC CATH RADIAL COMPRESSION DEV 20X24 EACH $68.00 270 $47.60 $34.00 $54.40 65% 80% 50% 50% 65% 65% 65% 48104848 CARDIAC CATH REMOTE 30 DAY ECG TECH SUPP EACH 93229 $777.00 732 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48104343 CARDIAC CATH REMOVE CARD RECORDER EACH "$1,433.00 " 481 "$1,003.10 " $716.50 "$1,146.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48104624 CARDIAC CATH REVASC W ILIAC STENT EACH "$26,275.00 " 360 "$18,392.50 " "$13,137.50 " "$21,020.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 48197230 CARDIAC CATH RFP-100A CONNECTOR CABLE EACH $375.00 272 $262.50 $187.50 $300.00 65% 80% 50% 50% 65% 65% 65% 48110258 CARDIAC CATH SAFESHEATH INTROD -CLS-1009.5 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110316 CARDIAC CATH SAFESHEATH INTROD -CLS-1010 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110308 CARDIAC CATH SAFESHEATH INTROD-CLS-1008.5 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110290 CARDIAC CATH SAFESHEATH INTROD-CLS-1010.5 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110282 CARDIAC CATH SAFESHEATH INTROD-CLS-1012.5 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110241 CARDIAC CATH SAFESHEATH INTRODUCER-CLS-1006 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110233 CARDIAC CATH SAFESHEATH INTRODUCER-CLS-1007 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110225 CARDIAC CATH SAFESHEATH INTRODUCER-CLS-1008 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110217 CARDIAC CATH SAFESHEATH INTRODUCER-CLS-1009 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110209 CARDIAC CATH SAFESHEATH INTRODUCER-CLS-1011 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48110191 CARDIAC CATH SAFESHEATH INTRODUCER-CLS-1012 EACH C1892 $125.00 278 $87.50 $62.50 $100.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107544 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 0 EACH C1817 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107551 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 1 EACH C1817 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107643 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 10 EACH C1817 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107569 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 2 EACH C1817 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107577 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 3 EACH C1817 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107585 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 4 EACH C1817 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107593 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 5 EACH C1817 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107601 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 6 EACH C1817 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107619 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 7 EACH C1817 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107627 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 8 EACH C1817 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107635 CARDIAC CATH SEPTAL DEFECT IMP SYS LVL 9 EACH C1817 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104939 CARDIAC CATH SET-UP CARDIOVERT-DEFIBRILL EACH 93745 $739.00 480 $517.30 $369.50 $591.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48197123 CARDIAC CATH SMALL CURL SSID-FST-085-00 EACH C1766 "$2,250.00 " 278 "$1,575.00 " "$1,125.00 " "$1,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196562 CARDIAC CATH SMALL CURL SSID-HST-085-00 EACH C1894 "$1,914.00 " 278 "$1,339.80 " $957.00 "$1,531.20 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48105381 CARDIAC CATH SMARTABLATE IRR TUBE SET EACH $243.00 272 $170.10 $121.50 $194.40 65% 80% 50% 50% 65% 65% 65% 48110001 CARDIAC CATH SOFT STYLETS-4090/100 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110068 CARDIAC CATH SOFT STYLETS-4090/40 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110050 CARDIAC CATH SOFT STYLETS-4090/46 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110043 CARDIAC CATH SOFT STYLETS-4090/52 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110035 CARDIAC CATH SOFT STYLETS-4090/58 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48110027 CARDIAC CATH SOFT STYLETS-4090/85 EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 48196539 CARDIAC CATH "SPLIT DIL, J GWIRE H-PLS-1006 " EACH C1894 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196547 CARDIAC CATH "SPLIT DIL, J GWIRE H-PLSH-1006" EACH C1894 $138.00 278 $96.60 $69.00 $110.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196554 CARDIAC CATH "SPLIT DIL, J GWIRE H-PLSH-1007" EACH C1894 $138.00 278 $96.60 $69.00 $110.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197172 CARDIAC CATH "SPLIT DIL, J GWIRE H-PLSH-1009" EACH C1894 $138.00 278 $96.60 $69.00 $110.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196596 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1006 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196604 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1007 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196612 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1008 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196620 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1008.5 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196638 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1009 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196646 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1009.5 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196653 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1010 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196661 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1010.5 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196679 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1011 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196687 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1012 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196695 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-1012.5 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196984 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-2506 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196992 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-2507 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197008 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-2508 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197016 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-2509 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197024 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-2510 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197032 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-2510.5 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197040 CARDIAC CATH "SPLIT DIL, J GWIRE-CLS-2511 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196521 CARDIAC CATH "SPLIT DIL, J GWIRE-FCL-160-10 " EACH C1894 $27.30 278 $19.11 $13.65 $21.84 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196588 CARDIAC CATH "SPLIT DIL, J GWIRE-HST-085-10 " EACH C1892 $47.00 278 $32.90 $23.50 $37.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196703 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1007 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196711 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1008 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196729 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1008.5 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196737 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1009 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196745 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1009.5 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196752 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1010 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196760 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1010.5 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196778 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1011 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196786 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1012 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196794 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-1012.5 " EACH C1892 $69.00 278 $48.30 $34.50 $55.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196802 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-2506 " EACH C1892 $88.00 278 $61.60 $44.00 $70.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196810 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-2507 " EACH C1892 $88.00 278 $61.60 $44.00 $70.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196828 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-2508 " EACH C1892 $88.00 278 $61.60 $44.00 $70.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196836 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-2509 " EACH C1892 $88.00 278 $61.60 $44.00 $70.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196844 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-2510 " EACH C1892 $88.00 278 $61.60 $44.00 $70.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196851 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-2510.5 " EACH C1892 $88.00 278 $61.60 $44.00 $70.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196869 CARDIAC CATH "SPLIT DIL, J GWIRE-PLS-2511 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196877 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1006 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196885 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1007 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196893 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1008 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196901 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1008.5" EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196919 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1009 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196927 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1009.5" EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196935 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1010 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196943 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1010.5" EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196950 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1011 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196968 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1012 " EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48196976 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-1012.5" EACH C1892 $118.00 278 $82.60 $59.00 $94.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197057 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-2506 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197065 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-2507 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197073 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-2508 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197081 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-2509 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197099 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-2510 " EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197107 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-2510.5" EACH C1892 $148.00 278 $103.60 $74.00 $118.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48197115 CARDIAC CATH "SPLIT DIL, J GWIRE-PLSX-2511 " EACH C1766 $88.00 278 $61.60 $44.00 $70.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48118517 CARDIAC CATH SQ EMBLEM S-ICD ELECTRODE EACH C1896 "$11,250.00 " 278 "$7,875.00 " "$5,625.00 " "$9,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191811 CARDIAC CATH STEER GUIDING SHEATH-LG CURVE EACH C1894 "$2,200.00 " 278 "$1,540.00 " "$1,100.00 " "$1,760.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191803 CARDIAC CATH STEER GUIDING SHEATH-MED CURVE EACH C1894 "$2,200.00 " 278 "$1,540.00 " "$1,100.00 " "$1,760.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191795 CARDIAC CATH STEER GUIDING SHEATH-SM CURVE EACH C1894 "$2,200.00 " 278 "$1,540.00 " "$1,100.00 " "$1,760.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106660 CARDIAC CATH STENT COAT W DEL LVL 0 EACH C1874 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106678 CARDIAC CATH STENT COAT W DEL LVL 1 EACH C1874 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106769 CARDIAC CATH STENT COAT W DEL LVL 10 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106686 CARDIAC CATH STENT COAT W DEL LVL 2 EACH C1874 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106694 CARDIAC CATH STENT COAT W DEL LVL 3 EACH C1874 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106702 CARDIAC CATH STENT COAT W DEL LVL 4 EACH C1874 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106710 CARDIAC CATH STENT COAT W DEL LVL 5 EACH C1874 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106728 CARDIAC CATH STENT COAT W DEL LVL 6 EACH C1874 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106736 CARDIAC CATH STENT COAT W DEL LVL 7 EACH C1874 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106744 CARDIAC CATH STENT COAT W DEL LVL 8 EACH C1874 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106751 CARDIAC CATH STENT COAT W DEL LVL 9 EACH C1874 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107650 CARDIAC CATH STENT COV W/O DEL SY LVL 0 EACH C1875 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107668 CARDIAC CATH STENT COV W/O DEL SY LVL 1 EACH C1875 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107759 CARDIAC CATH STENT COV W/O DEL SY LVL 10 EACH C1875 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107676 CARDIAC CATH STENT COV W/O DEL SY LVL 2 EACH C1875 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107684 CARDIAC CATH STENT COV W/O DEL SY LVL 3 EACH C1875 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107692 CARDIAC CATH STENT COV W/O DEL SY LVL 4 EACH C1875 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107700 CARDIAC CATH STENT COV W/O DEL SY LVL 5 EACH C1875 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107718 CARDIAC CATH STENT COV W/O DEL SY LVL 6 EACH C1875 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107726 CARDIAC CATH STENT COV W/O DEL SY LVL 7 EACH C1875 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107734 CARDIAC CATH STENT COV W/O DEL SY LVL 8 EACH C1875 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48107742 CARDIAC CATH STENT COV W/O DEL SY LVL 9 EACH C1875 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106777 CARDIAC CATH STENT NON COAT W DEL LVL 0 EACH C1876 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106785 CARDIAC CATH STENT NON COAT W DEL LVL 1 EACH C1876 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106876 CARDIAC CATH STENT NON COAT W DEL LVL 10 EACH C1876 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106793 CARDIAC CATH STENT NON COAT W DEL LVL 2 EACH C1876 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106801 CARDIAC CATH STENT NON COAT W DEL LVL 3 EACH C1876 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106819 CARDIAC CATH STENT NON COAT W DEL LVL 4 EACH C1876 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106827 CARDIAC CATH STENT NON COAT W DEL LVL 5 EACH C1876 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106835 CARDIAC CATH STENT NON COAT W DEL LVL 6 EACH C1876 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106843 CARDIAC CATH STENT NON COAT W DEL LVL 7 EACH C1876 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106850 CARDIAC CATH STENT NON COAT W DEL LVL 8 EACH C1876 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106868 CARDIAC CATH STENT NON COAT W DEL LVL 9 EACH C1876 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106884 CARDIAC CATH STENT NON COAT WO DEL LVL 0 EACH C1877 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106892 CARDIAC CATH STENT NON COAT WO DEL LVL 1 EACH C1877 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106983 CARDIAC CATH STENT NON COAT WO DEL LVL 10 EACH C1877 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106900 CARDIAC CATH STENT NON COAT WO DEL LVL 2 EACH C1877 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106918 CARDIAC CATH STENT NON COAT WO DEL LVL 3 EACH C1877 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106926 CARDIAC CATH STENT NON COAT WO DEL LVL 4 EACH C1877 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106934 CARDIAC CATH STENT NON COAT WO DEL LVL 5 EACH C1877 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106942 CARDIAC CATH STENT NON COAT WO DEL LVL 6 EACH C1877 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106959 CARDIAC CATH STENT NON COAT WO DEL LVL 7 EACH C1877 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106967 CARDIAC CATH STENT NON COAT WO DEL LVL 8 EACH C1877 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48106975 CARDIAC CATH STENT NON COAT WO DEL LVL 9 EACH C1877 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191829 CARDIAC CATH SUPERIOR-ACCESS TRANSSEPT KIT EACH C1894 "$4,375.00 " 278 "$3,062.50 " "$2,187.50 " "$3,500.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104301 CARDIAC CATH TEMP PACEMAKER EACH "$18,427.00 " 481 "$12,898.90 " "$9,213.50 " "$14,741.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable $3889/case "$3,785 " "$3,785 " 48190458 CARDIAC CATH TENDRIL SDX -1688TC/25 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190441 CARDIAC CATH TENDRIL SDX -1688TC/34 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190433 CARDIAC CATH TENDRIL SDX -1688TC/40 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190425 CARDIAC CATH TENDRIL SDX -1688TC/46 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190417 CARDIAC CATH TENDRIL SDX -1688TC/52 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190409 CARDIAC CATH TENDRIL SDX -1688TC/58 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190383 CARDIAC CATH TENDRIL ST OPTIM-1882TC/46 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190375 CARDIAC CATH TENDRIL ST OPTIM-1882TC/52 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190367 CARDIAC CATH TENDRIL ST OPTIM-1888TC/46 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190359 CARDIAC CATH TENDRIL ST OPTIM-1888TC/52 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190342 CARDIAC CATH TENDRIL ST OPTIM-1888TC/58 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190334 CARDIAC CATH TENDRIL ST OPTIM-1888TC/65 EACH C1883 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190391 CARDIAC CATH TENDRIL STS-2088TC/100 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190490 CARDIAC CATH TENDRIL STS-2088TC/46 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190482 CARDIAC CATH TENDRIL STS-2088TC/52 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190474 CARDIAC CATH TENDRIL STS-2088TC/58 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190466 CARDIAC CATH TENDRIL STS-2088TC/65 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190326 CARDIAC CATH TENDRL MRI PM LEAD-LPA1200M/46 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190318 CARDIAC CATH TENDRL MRI PM LEAD-LPA1200M/52 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190300 CARDIAC CATH TENDRL MRI PM LEAD-LPA1200M/58 EACH C1898 "$1,250.00 " 278 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191787 CARDIAC CATH TF TRANSPET (C1 T85-32-63-45) EACH C1894 "$1,625.00 " 278 "$1,137.50 " $812.50 "$1,300.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191761 CARDIAC CATH TF TRANSPET (C1 T85-32-63-55) EACH C1894 "$1,625.00 " 278 "$1,137.50 " $812.50 "$1,300.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191746 CARDIAC CATH TF TRANSPET (C1 T85-32-63-90) EACH C1894 "$1,625.00 " 278 "$1,137.50 " $812.50 "$1,300.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191779 CARDIAC CATH TF TRANSPET (CO T85-32-63-45) EACH C1894 "$1,625.00 " 278 "$1,137.50 " $812.50 "$1,300.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191753 CARDIAC CATH TF TRANSPET (CO T85-32-63-55) EACH C1894 "$1,625.00 " 278 "$1,137.50 " $812.50 "$1,300.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191738 CARDIAC CATH TF TRANSPET (CO T85-32-63-90) EACH C1894 "$1,625.00 " 278 "$1,137.50 " $812.50 "$1,300.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195721 CARDIAC CATH ULTRASOUND CATH-08255790 EACH C1753 "$8,283.00 " 278 "$5,798.10 " "$4,141.50 " "$6,626.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195796 CARDIAC CATH ULTRASOUND CATH-10043342 EACH C1759 "$8,283.00 " 278 "$5,798.10 " "$4,141.50 " "$6,626.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195804 CARDIAC CATH ULTRASOUND CATH-10135910 EACH C1759 "$8,283.00 " 278 "$5,798.10 " "$4,141.50 " "$6,626.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195739 CARDIAC CATH ULTRASOUND CATH-10135936 EACH C1753 "$8,283.00 " 278 "$5,798.10 " "$4,141.50 " "$6,626.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195754 CARDIAC CATH ULTRASOUND CATH-10438577 EACH C1759 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195713 CARDIAC CATH ULTRASOUND CATH-10439011 EACH C1753 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195747 CARDIAC CATH ULTRASOUND CATH-10439072 EACH C1759 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195770 CARDIAC CATH ULTRASOUND CATH-10439236 EACH C1759 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195762 CARDIAC CATH ULTRASOUND CATH-SNDSTR10 EACH C1759 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48195788 CARDIAC CATH ULTRASOUND CATH-SNDSTR10G EACH C1759 "$7,988.00 " 278 "$5,591.60 " "$3,994.00 " "$6,390.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191514 CARDIAC CATH UNIFY ASSURA CRT-D-CD3357-40C EACH C1882 "$45,000.00 " 278 "$31,500.00 " "$22,500.00 " "$36,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191506 CARDIAC CATH UNIFY ASSURA CRT-D-CD3357-40Q EACH C1882 "$45,000.00 " 278 "$31,500.00 " "$22,500.00 " "$36,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191571 CARDIAC CATH UQ CRT-D SYS MERLI-CD3357-40C EACH C2621 "$55,000.00 " 278 "$38,500.00 " "$27,500.00 " "$44,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191563 CARDIAC CATH UQ CRT-D SYS MERLI-CD3357-40Q EACH C2621 "$55,000.00 " 278 "$38,500.00 " "$27,500.00 " "$44,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191555 CARDIAC CATH UQ CRT-D SYSTEM-CD3357-40C SYS EACH C2621 "$55,000.00 " 278 "$38,500.00 " "$27,500.00 " "$44,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48191548 CARDIAC CATH UQ CRT-D SYSTEM-CD3357-40Q SYS EACH C2621 "$55,000.00 " 278 "$38,500.00 " "$27,500.00 " "$44,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48104657 CARDIAC CATH VALVE FLUORO EACH $400.00 329 $280.00 $200.00 $320.00 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 48190672 CARDIAC CATH VERITY ADX DR M/S PM-5357 M/S EACH C1785 "$8,000.00 " 278 "$5,600.00 " "$4,000.00 " "$6,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190631 CARDIAC CATH VERITY ADX SR M/S PM-5157M/S EACH C1786 "$7,750.00 " 278 "$5,425.00 " "$3,875.00 " "$6,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190706 CARDIAC CATH ZEPHYR DR PACEMAKER-5820 EACH C1785 "$8,000.00 " 278 "$5,600.00 " "$4,000.00 " "$6,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190698 CARDIAC CATH ZEPHYR DR XL PACEMAKER-5826 EACH C1785 "$8,000.00 " 278 "$5,600.00 " "$4,000.00 " "$6,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190664 CARDIAC CATH ZEPHYR SR PACEMAKER-5620 EACH C1786 "$7,750.00 " 278 "$5,425.00 " "$3,875.00 " "$6,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48190656 CARDIAC CATH ZEPHYR SR XL PACEMAKER-5626 EACH C1786 "$7,750.00 " 278 "$5,425.00 " "$3,875.00 " "$6,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 48000392 CARDIOLOGY AMB BP MON 24 HR R/S/I&R EACH 93784 $308.32 480 $215.82 $154.16 $246.66 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000400 CARDIOLOGY AMBULATORY BP ANLYS EACH 93788 $316.00 480 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000475 CARDIOLOGY ANLYS PCMKR ANTITACHYCARDIA EACH 93724 $739.00 480 $517.30 $369.50 $591.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000566 CARDIOLOGY CARDIOVASCULAR UNLSTD PROC EACH 93799 $387.00 480 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48010714 CARDIOLOGY CARDIOVERSION EACH 92960 "$1,610.00 " 480 "$1,127.00 " $805.00 "$1,288.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000004 CARDIOLOGY CONTRAST INJECTABLE MEDIA ECHO EACH A9700 $337.00 255 $235.90 $168.50 $269.60 65% 80% 50% 50% 65% 65% 65% 48000582 CARDIOLOGY CONTRAST LOCM 150-199MG/ML 1ML EACH Q9965 $4.00 255 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% 48000590 CARDIOLOGY CONTRAST LOCM 200-299MG 1ML EACH Q9966 $2.00 255 $1.40 $1.00 $1.60 65% 80% 50% 50% 65% 65% 65% 48000608 CARDIOLOGY CONTRAST LOCM 300-399MG 1ML EACH Q9967 $2.00 255 $1.40 $1.00 $1.60 65% 80% 50% 50% 65% 65% 65% 48000616 CARDIOLOGY CONTRAST LOW OSMOLAR 400MG >1M EACH Q9951 $2.00 255 $1.40 $1.00 $1.60 65% 80% 50% 50% 65% 65% 65% 48000012 CARDIOLOGY ECHO 2D W/W/O M-MODE CMPL EACH 93307 $606.00 483 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000038 CARDIOLOGY ECHO COLOR FLOW MAPPING EACH 93325 $296.00 483 $207.20 $148.00 $236.80 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000046 CARDIOLOGY ECHO CONGENITAL ANOMALY CMPL EACH 93303 "$1,365.00 " 483 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000053 CARDIOLOGY ECHO CONGENITAL ANOMALY LTD EACH 93304 "$1,365.00 " 483 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000061 CARDIOLOGY ECHO DOPPLER CMPL EACH 93320 $356.87 483 $249.81 $178.44 $285.50 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000079 CARDIOLOGY ECHO DOPPLER LTD EACH 93321 $190.00 483 $133.00 $95.00 $152.00 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000087 CARDIOLOGY ECHO REST & STRESS W/PF EACH 93350 "$1,365.00 " 483 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48010433 CARDIOLOGY ECHO TEE (TRANSESOPHGEAL) EACH 93312 "$1,365.00 " 483 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000095 CARDIOLOGY ECHO TEE 2D PROBE PLMNT MONITO EACH C8927 "$1,980.00 " 483 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000103 CARDIOLOGY ECHO TEE 2D W/CONT INTERP/REP EACH C8925 "$1,980.00 " 483 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000111 CARDIOLOGY ECHO TEE ANOMALY CMPL W/PF EACH 93315 "$1,365.00 " 483 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000129 CARDIOLOGY ECHO TEE ANOMALY IMAGE W/PF EACH 93317 $880.00 483 $616.00 $440.00 $704.00 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000137 CARDIOLOGY ECHO TEE ANOMALY PROBE PLMNT EACH 93316 "$1,365.00 " 483 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000145 CARDIOLOGY ECHO TEE ANOMALY W/CONTRAST EACH C8926 "$1,980.00 " 483 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000178 CARDIOLOGY ECHO TEE MONITORING EACH 93318 "$1,365.00 " 483 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000186 CARDIOLOGY ECHO TEE PROBE PLACEMENT EACH 93313 "$1,365.00 " 483 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000194 CARDIOLOGY ECHO TRANSTHO 2D STRESS INTERP EACH C8928 "$1,980.00 " 483 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48010615 CARDIOLOGY ECHO TTE COMPLETE W/CONTRAST EACH 93306 "$1,980.00 " 483 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48010623 CARDIOLOGY ECHO TTE LIMITED W/CONTRAST EACH 93308 $951.00 483 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000624 CARDIOLOGY EECP EACH G0166 $316.00 480 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48010490 CARDIOLOGY EXT ECG>48HR<7D SCAN A/R EACH 93243 $316.00 731 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48010722 CARDIOLOGY MYOCARDIAL CONTRAST PERFUSION EACH 0439T $50.00 480 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48010409 CARDIOLOGY PM DEVICE INTERROGATE REMOTE EACH 93294 $133.00 960 $93.10 $66.50 $106.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 48010417 CARDIOLOGY STRESS TEST ONLY (NO IMAGING) EACH 93017 $777.00 482 $543.90 $388.50 $621.60 65% of Billed Charges 80% Covered Charges NTE $1501/case $440/visit $400/visit $36.29 Non Payable Non Payable 48000202 CARDIOLOGY TRANSTHO ANOMALY CMPL W/CONT EACH C8921 "$1,980.00 " 483 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000210 CARDIOLOGY TRANSTHO ANOMALY LIMITED W/CO EACH C8922 "$1,980.00 " 483 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000236 CARDIOLOGY TRANSTHOR 2D LIMITED W/CONT EACH C8924 $951.00 483 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48000673 CARDIOLOGY "TTE W OR WO FOL WCON,DOPPLER " EACH C8929 "$1,980.00 " 483 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 48010748 CARDIOLOGY USE OF CONTRAST AGENT W ECHO EACH 93352 $150.00 519 $105.00 $75.00 $120.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000092 CHEMOTHERAPY CHEMO IA INFS ADD HR EACH 96423 $118.00 335 $82.60 $59.00 $94.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000084 CHEMOTHERAPY CHEMO IA INFUSION 1 HR EACH 96422 $838.00 335 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000209 CHEMOTHERAPY CHEMO IA PUSH EACH 96420 $838.00 331 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000126 CHEMOTHERAPY CHEMO INJ SUBARACH/INTRAVENT EACH 96542 $838.00 331 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000050 CHEMOTHERAPY CHEMO IV INFUSION ADD HR EACH 96415 $175.00 335 $122.50 $87.50 $140.00 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000076 CHEMOTHERAPY CHEMO IV INFUSION EACH ADD <1H EACH 96417 $175.00 335 $122.50 $87.50 $140.00 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000068 CHEMOTHERAPY CHEMO IV INFUSION PRO W/PUMP EACH 96416 $838.00 335 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000043 CHEMOTHERAPY CHEMO IV INFUSION SGL/INIT<1H EACH 96413 $838.00 335 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000035 CHEMOTHERAPY CHEMO IV PUSH ADDITIONAL DRUG EACH 96411 $175.00 331 $122.50 $87.50 $140.00 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000027 CHEMOTHERAPY CHEMO IV PUSH SINGLE/INITIAL EACH 96409 $838.00 331 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000134 CHEMOTHERAPY CHEMO SQ/IM NON ANTI-NEOPLAST EACH 96401 $175.00 331 $122.50 $87.50 $140.00 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000142 CHEMOTHERAPY CHEMOTHERAPY INTO CNS EACH 96450 $838.00 331 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33000118 CHEMOTHERAPY IRRIGAT IMPLANT VEN ACCESS DEV EACH 96523 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 33000100 CHEMOTHERAPY PUMP PORTABLE MAINT/REFILL EACH 96521 $530.00 510 $371.00 $265.00 $424.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945673 CLINIC ABLATE INF TURB SUBMUC EACH 30802 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945665 CLINIC ABLATE INF TURB SUPERF EACH 30801 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941847 CLINIC ABRASION LESION SINGLE EACH 15786 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951085 CLINIC ABRASIONLESNADD4ORLESS EACH 15787 $150.00 510 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940112 CLINIC ACNE SURGERY EACH 10040 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51949873 CLINIC ACTINOTHERAPY (UV LIGHT) EACH 96900 $100.00 510 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% Non Payable Non Payable 51906410 CLINIC ACUPUNCT W/O STIMUL 15 MIN EACH 97810 $0.00 374 $0.00 $0.00 $0.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51906428 CLINIC ACUPUNCT W/O STIMUL ADDL 15M EACH 97811 $0.00 374 $0.00 $0.00 $0.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51906436 CLINIC ACUPUNCT W/STIMUL 15 MIN EACH 97813 $0.00 374 $0.00 $0.00 $0.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51906444 CLINIC ACUPUNCT W/STIMUL ADDL 15M EACH 97814 $0.00 374 $0.00 $0.00 $0.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51945426 CLINIC ADD WALKER TO CAST EACH 29440 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51907186 CLINIC ADMIN HEPATITIS B VACCINE EACH G0010 $118.00 771 $82.60 $59.00 $94.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51907210 CLINIC ADMIN INFLUENZA VACCINE EACH G0008 $118.00 771 $82.60 $59.00 $94.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51903698 CLINIC ADMIN OTHER VACCINE EACH 90471 $175.00 771 $122.50 $87.50 $140.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51907178 CLINIC ADMIN PNEUMOCOCCAL VACCINE EACH G0009 $118.00 771 $82.60 $59.00 $94.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51952547 CLINIC ADULTDEPRESSIONSCREEN EACH G0444 $71.00 510 $49.70 $35.50 $56.80 65% 80% 50% 50% 65% Non Payable Non Payable 51952406 CLINIC ADVANCEDCAREPLAN+30 EACH 99498 $68.00 510 $47.60 $34.00 $54.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952398 CLINIC ADVANCEDCAREPLAN-30MIN EACH 99497 $221.00 510 $154.70 $110.50 $176.80 65% 80% 50% 50% 65% Non Payable Non Payable 51921732 Clinic AI-ALYS CPLX CN NPGT PRGRMG EACH 95977 $240.00 960 $168.00 $120.00 $192.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51921724 Clinic AI-ALYS SMPL CN NPGT PRGRMG EACH 95976 $94.00 960 $65.80 $47.00 $75.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51921526 Clinic AI-CLOSE TEAR DUCT OPENING EACH 68760 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51921450 Clinic AI-MDFC FLAP W/PRSRV VSC PEDCL EACH 15730 "$8,871.00 " 510 "$6,209.70 " "$4,435.50 " "$7,096.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51921468 Clinic AI-OCULAR RECONST TRANSPLANT EACH 65780 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51921500 Clinic AI-RECONSTRUCTION OF EYELID EACH 67973 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51921484 Clinic AI-REPAIR EYELID DEFECT EACH 67902 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51921476 Clinic AI-REVISE EYELASHES EACH 67825 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51921518 Clinic AI-REVISE/GRAFT EYELID LINING EACH 68335 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51908135 CLINIC "AMINES, VAGINAL FLUID QUAL-POC" EACH 82120 $40.00 301 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $1.94 $1.94 $4.85 65% of Billed Charges 65% of Billed Charges 51952042 CLINIC AMNIOTICFLUIDREDUCTW/US EACH 59001 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943561 CLINIC AMPUTATION FOOT AT ANKLE EACH 27888 "$12,574.00 " 510 "$8,801.80 " "$6,287.00 " "$10,059.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945178 CLINIC AMPUTATION OF MIDFOOT EACH 28800 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945202 CLINIC AMPUTATION OF TOE EACH 28820 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945186 CLINIC AMPUTATION THRU METATARSAL EACH 28805 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945194 CLINIC AMPUTATION TOE & METATARS EACH 28810 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947620 CLINIC ANALYZE IMPLANT PUMP W/O EACH 62367 $739.00 510 $517.30 $369.50 $591.20 65% 80% 50% 50% 65% Non Payable Non Payable 51947653 CLINIC ANL SP INF PMP W/REPRG&FIL EACH 62370 $739.00 510 $517.30 $369.50 $591.20 65% 80% 50% 50% 65% Non Payable Non Payable 51949790 CLINIC ANLYS NEUR CPLX 1ST H W/PR EACH 95972 $240.00 510 $168.00 $120.00 $192.00 65% 80% 50% 50% 65% Non Payable Non Payable 51949774 CLINIC ANLYS NEUR W/O PROG SIMPLE EACH 95970 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51949782 CLINIC ANLYS NEUR W/PROG SIMPLE EACH 95971 $240.00 510 $168.00 $120.00 $192.00 65% 80% 50% 50% 65% Non Payable Non Payable 51947638 CLINIC ANLYS PAIN PUMP W/PROG EACH 62368 $739.00 510 $517.30 $369.50 $591.20 65% 80% 50% 50% 65% Non Payable Non Payable 51952596 CLINIC ANNUALALCOHOLSCR15 EACH G0442 $71.00 510 $49.70 $35.50 $56.80 65% 80% 50% 50% 65% Non Payable Non Payable 51946416 CLINIC ANOCOPY-REM LES (SNARE) EACH 46611 "$2,260.00 " 510 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946408 CLINIC ANOCOPY-REMOVE LES (SNARE) EACH 46610 "$6,943.00 " 510 "$4,860.10 " "$3,471.50 " "$5,554.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51906238 CLINIC ANORECTAL MANOMETRY EACH 91122 $777.00 750 $543.90 $388.50 $621.60 65% 80% Covered Charges NTE $1501/case $88 $80 $247.34 Non Payable Non Payable 51946390 CLINIC ANOSCOPY - REMOVE FB EACH 46608 "$2,260.00 " 510 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946432 CLINIC ANOSCOPY - W/ABLATION EACH 46615 "$6,943.00 " 510 "$4,860.10 " "$3,471.50 " "$5,554.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946382 CLINIC ANOSCOPY AND BIOPSY EACH 46606 "$2,918.00 " 510 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946374 CLINIC ANOSCOPY AND DILATION EACH 46604 "$2,918.00 " 510 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946424 CLINIC ANOSCOPY CONTROL BLEEDING EACH 46614 "$2,918.00 " 510 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951846 CLINIC ANOSCOPYREMOVELESIONS EACH 46612 "$6,943.00 " 750 "$4,860.10 " "$3,471.50 " "$5,554.40 " 65% 80% Covered Charges NTE $1501/case "$1,023 " $930 $102.00 $824 $824 51948719 CLINIC ANTERIOR CHAMBER - MEDS EACH 66030 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945509 CLINIC APPL COMPRS BELOW KNEE EACH 29581 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945293 CLINIC APPL FINGER SPLINT STATIC EACH 29130 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51945517 CLINIC APPL MULT COMPRS ARM/HAND EACH 29584 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945228 CLINIC APPLY CAST - LONG ARM EACH 29065 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945236 CLINIC APPLY CAST - SHORT ARM EACH 29075 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945251 CLINIC APPLY CAST FINGER EACH 29086 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945244 CLINIC APPLY CAST HAND/FOREARM EACH 29085 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945442 CLINIC APPLY CLUBFOOT CAST W/MOLD EACH 29450 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945384 CLINIC APPLY CYLINDER CAST - LEG EACH 29365 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945301 CLINIC APPLY FINGER SPLINT DYN EACH 29131 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51945277 CLINIC APPLY FOREARM SPLNT STATIC EACH 29125 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51945335 CLINIC APPLY HIP SPICA CAST 1 LEG EACH 29305 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945343 CLINIC APPLY HIP SPICA CAST BOTH EACH 29325 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945350 CLINIC APPLY LONG LEG CAST EACH 29345 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945368 CLINIC APPLY LONG LEG CAST - WALK EACH 29355 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945376 CLINIC APPLY LONG LEG CAST BRACE EACH 29358 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945418 CLINIC APPLY PATELLAR CAST EACH 29435 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945434 CLINIC APPLY RIGID TOTAL LEG CAST EACH 29445 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945285 CLINIC APPLY SHORT ARM SPLINT DYN EACH 29126 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51945392 CLINIC APPLY SHORT LEG CAST EACH 29405 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945400 CLINIC APPLY SHORT LEG CAST WALK EACH 29425 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951556 CLINIC "APPLYBODYCAST,MINERVA " EACH 29040 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951572 CLINIC APPLYBODYCASTBOTHTHIGHS EACH 29046 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951549 CLINIC APPLYBODYCASTSHOULDHIPS EACH 29035 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951564 CLINIC APPLYBODYCASTW/ONETHIGH EACH 29044 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951580 CLINIC APPLYCASTFIGURE-OF-8 EACH 29049 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951606 CLINIC APPLYCASTPLASTERVELPEAU EACH 29058 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951598 CLINIC APPLYCASTSHOULDERSPICA EACH 29055 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951523 CLINIC APPLYHALOTYPEBODYCAST EACH 29010 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951531 CLINIC APPLYRISSERJACKETBODY/HD EACH 29015 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51943744 CLINIC ARTHROT W/BX INTER/TAR JT EACH 28050 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943660 CLINIC ARTHROTOMY INTERPHAL JT EACH 28024 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943645 CLINIC ARTHROTOMY INTERT/TARS JT EACH 28020 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943652 CLINIC ARTHROTOMY METATARS JOINT EACH 28022 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943769 CLINIC ARTHROTOMY W BX INTERPH JT EACH 28054 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943751 CLINIC ARTHROTOMY W BX METATAR JT EACH 28052 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949048 CLINIC ASP ORBITAL CONTENTS EACH 67415 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942597 CLINIC ASP/INJ GANGLION CYST EACH 20612 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 51951218 CLINIC ASP/INJCYSTBONE EACH 20615 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951697 CLINIC ASPCATHNASOTRACHEAL EACH 31720 $528.00 510 $369.60 $264.00 $422.40 65% 80% 50% 50% 65% Non Payable Non Payable 51919637 CLINIC ASTHMA EDUCATION-GROUP 2-4 EACH 98961 $75.00 942 $52.50 $37.50 $60.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919645 CLINIC ASTHMA EDUCATION-GROUP 5-8 EACH 98962 $48.00 942 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919629 CLINIC ASTHMA EDUCATION-INDIVIDUAL EACH 98960 $96.00 942 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51918746 CLINIC ASTRAZENECA COV19 ADMIN DOSE 1 EACH 0021A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51918753 CLINIC ASTRAZENECA COV19 ADMIN DOSE 2 EACH 0022A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51940971 CLINIC AVULSION NAIL PLATE EA ADD EACH 11732 $150.00 510 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940963 CLINIC AVULSION NAIL PLATE SINGLE EACH 11730 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51906725 CLINIC BINOCULAR MICROSCOPY EACH 92504 $50.00 510 $35.00 $25.00 $40.00 65% 80% 50% 50% 65% Non Payable Non Payable 51952158 CLINIC BIOFEEDBACKTRAINANY EACH 90901 $49.00 917 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51942944 CLINIC BIOPSY ARM/ELB SOFT TISS EACH 24065 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943371 CLINIC BIOPSY LOWER LEG TISSUE EACH 27613 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942324 CLINIC BIOPSY OF BREAST OPEN EACH 19101 "$9,425.00 " 510 "$6,597.50 " "$4,712.50 " "$7,540.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947174 CLINIC BIOPSY OF CERVIX EACH 57500 "$1,988.00 " 510 "$1,391.60 " $994.00 "$1,590.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946028 CLINIC BIOPSY OF LIP EACH 40490 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% Non Payable Non Payable 51946168 CLINIC "BIOPSY OF PALATE, UVULA " EACH 42100 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946796 CLINIC BIOPSY OF PENIS EACH 54100 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946853 CLINIC BIOPSY OF PROSTATE EACH 55700 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943264 CLINIC BIOPSY OF SOFT TISSUES EACH 27040 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946085 CLINIC BIOPSY OF TONGUE EACH 41100 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946960 CLINIC BIOPSY OF VULVA/PERINEUM EACH 56606 $500.00 510 $350.00 $250.00 $400.00 65% 80% 50% 50% 65% Non Payable Non Payable 51943025 CLINIC BIOPSY OF WRIST JOINT EACH 25100 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946093 CLINIC "BIOPSY, FLOOR OF MOUTH " EACH 41108 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945624 CLINIC "BIOPSY, INTRANASAL " EACH 30100 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946069 CLINIC "BIOPSY, VESTIBULE OF MOUTH " EACH 40808 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946010 CLINIC BIOPSY/REMOVAL LYMPH NODES EACH 38510 "$9,425.00 " 510 "$6,597.50 " "$4,712.50 " "$7,540.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951994 CLINIC BIOPSYOFEPIDIDYMIS EACH 54800 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945863 CLINIC BL DRAW < 3 YRS SCALP VEIN EACH 36405 $42.00 510 $29.40 $21.00 $33.60 65% 80% 50% 50% 65% Non Payable Non Payable 51941870 CLINIC BLEPHAROPLASTY LOW EYELID EACH 15820 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941896 CLINIC BLEPHAROPLASTY UP EYELID EACH 15822 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952604 CLINIC BRALCOHOLMISUSECOUNS EACH G0443 $221.00 510 $154.70 $110.50 $176.80 65% 80% 50% 50% 65% Non Payable Non Payable 51906220 CLINIC BREATH HYDROGEN TEST EACH 91065 $387.00 750 $270.90 $193.50 $309.60 65% 80% Covered Charges NTE $1501/case $88 $80 $78.34 Non Payable Non Payable 51945814 CLINIC BRONCH EBUS SAMPL 1/2 NODE EACH 31652 "$9,260.00 " 510 "$6,482.00 " "$4,630.00 " "$7,408.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 75102145 CLINIC BRONCHOSCOPY CLEAR AIRWAYS EACH 31645 "$4,197.00 " 510 "$2,937.90 " "$2,098.50 " "$3,357.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 75102152 CLINIC BRONCHOSCOPY RECLEAR AIRWAY EACH 31646 "$1,010.00 " 510 $707.00 $505.00 $808.00 65% 80% 50% 50% 65% Non Payable Non Payable 75102129 CLINIC BRONCHOSCOPY W/FB REMOVAL EACH 31635 "$4,197.00 " 510 "$2,937.90 " "$2,098.50 " "$3,357.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 75102061 CLINIC BRONCHOSCOPY W/MARKERS EACH 31626 "$16,923.00 " 510 "$11,846.10 " "$8,461.50 " "$13,538.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 75102137 CLINIC BRONCHOSCOPY W/TUMOR EXCISE EACH 31640 "$9,260.00 " 510 "$6,482.00 " "$4,630.00 " "$7,408.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 75102103 CLINIC BRONCHOSCOPY/LUNG BX ADDL EACH 31632 "$2,279.00 " 510 "$1,595.30 " "$1,139.50 " "$1,823.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951689 CLINIC BRONCHOSCOPY/LUNGBXEACH EACH 31628 "$9,260.00 " 510 "$6,482.00 " "$4,630.00 " "$7,408.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 75102111 CLINIC BRONCHOSCOPY/NEEDLE BX ADDL EACH 31633 "$1,910.00 " 510 "$1,337.00 " $955.00 "$1,528.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 75102095 CLINIC BRONCHOSCOPY/NEEDLE BX EACH EACH 31629 "$9,260.00 " 510 "$6,482.00 " "$4,630.00 " "$7,408.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942290 CLINIC BX BREAST 1ST LES STEREO EACH 19081 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942365 CLINIC BX BRST W/LOC + LES MAMMO EACH 19282 $592.00 510 $414.40 $296.00 $473.60 65% 80% 50% 50% 65% Non Payable Non Payable 51948578 CLINIC BX CORNEA EACH 65410 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949667 CLINIC BX EAR EXTERNAL EACH 69100 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% Non Payable Non Payable 51947224 CLINIC BX ENDOMETRIAL SAMPL W/O EACH 58100 $493.00 510 $345.10 $246.50 $394.40 65% 80% 50% 50% 65% Non Payable Non Payable 51946952 CLINIC BX LESN VULVA/PER 1 LESN EACH 56605 "$1,988.00 " 510 "$1,391.60 " $994.00 "$1,590.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943389 CLINIC BX LOWER LEG TISSUE DEEP EACH 27614 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947026 CLINIC BX MUCOSA VAGINAL SMP EACH 57100 "$1,988.00 " 510 "$1,391.60 " $994.00 "$1,590.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941003 CLINIC BX NAIL UNIT EACH 11755 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947158 CLINIC BX OF CERVIX W/SCOPE LEEP EACH 57460 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946861 CLINIC BX PROSTATE INCISIONAL EACH 55705 "$8,620.00 " 510 "$6,034.00 " "$4,310.00 " "$6,896.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945996 CLINIC BX/REMOVAL LYMPH NODES EACH 38500 "$9,425.00 " 510 "$6,597.50 " "$4,712.50 " "$7,540.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51919660 CLINIC CARB COUNTING EDUC-GROUP 2-4 EACH 98961 $72.00 942 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919678 CLINIC CARB COUNTING EDUC-GROUP 5-8 EACH 98962 $48.00 942 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919652 CLINIC CARB COUNTING EDUC-INDIVIDUAL EACH 98960 $96.00 942 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51948404 CLINIC CARPAL TUNNEL SURGERY EACH 64721 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952513 CLINIC CASCREEN-PELVIC/BREASTEX EACH G0101 $221.00 770 $154.70 $110.50 $176.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51948834 CLINIC CATARACT SUR W/IOL 1 STAGE EACH 66984 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946622 CLINIC CATH BLADDER INDWELL CPLX EACH 51703 $387.00 510 $270.90 $193.50 $309.60 65% 80% 50% 50% 65% Non Payable Non Payable 51946606 CLINIC CATH BLADDER NON-INDWELL EACH 51701 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51947190 CLINIC CAUT CERVIX ELECTR/THERMAL EACH 57510 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942035 CLINIC CAUT CHEM TISSUE GRAN EACH 17250 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951119 CLINIC CERVICOPLASTY EACH 15819 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946234 CLINIC CHANGE GASTROSTOMY TUBE EACH 43762 $612.00 510 $428.40 $306.00 $489.60 65% 80% 50% 50% 65% Non Payable Non Payable 51941862 CLINIC CHEM PEEL NON-FACIAL EPID EACH 15792 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941854 CLINIC CHEMICAL PEEL FACIAL EPID EACH 15788 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51951093 CLINIC CHEMICALPEELFACIALDERMAL EACH 15789 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51919538 CLINIC CHEMO IA PROLONGED (>8 HR) EACH 96425 $838.00 335 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51919439 CLINIC CHEMO INTRALESIONAL UP TO 7 EACH 96405 $175.00 331 $122.50 $87.50 $140.00 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51908143 CLINIC CHEMO SQ/IM ANTI-NEOPLASTIC EACH 96402 $175.00 331 $122.50 $87.50 $140.00 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51948305 CLINIC CHEMODEN 1 EXTR 1-4 MUSC EACH 64642 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949022 CLINIC CHEMODENERV MUSCLE XOCULAR EACH 67345 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51919546 CLINIC CHEMOTHERAPY INTRACAVITARY EACH 96440 $838.00 331 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51919611 CLINIC CHEMOTHERAPY UNSPECIFIED EACH 96549 $118.00 331 $82.60 $59.00 $94.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51919553 CLINIC CHEMOTX ADMN PRTL CAVITY EACH 96446 $838.00 331 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51951101 CLINIC CHEMPEELNON-FACIALDERMAL EACH 15793 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51946630 CLINIC CHG TUBE CYSTOSTOMY SMP EACH 51705 $612.00 510 $428.40 $306.00 $489.60 65% 80% 50% 50% 65% Non Payable Non Payable 51945772 CLINIC CHG TUBE TRACHEOTOMY EACH 31502 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% Non Payable Non Payable 51952646 CLINIC CHRNC CARE MGMT SVC 1ST 20 EACH 99490 $221.00 510 $154.70 $110.50 $176.80 65% 80% 50% 50% 65% Non Payable Non Payable 51946804 CLINIC CIRC W/O CLAMP >28 DAYS EACH 54161 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951952 CLINIC CIRCUMCISIONW/REGBLOCK EACH 54150 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951960 CLINIC CIRCW/OCLAMPNEONATE EACH 54160 "$1,689.00 " 510 "$1,182.30 " $844.50 "$1,351.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942746 CLINIC CL TX PALATAL/ MAXI FRACT EACH 21421 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941540 CLINIC CMPLX RPR E/N/E/L ADDL 5CM EACH 13153 $269.00 510 $188.30 $134.50 $215.20 65% 80% 50% 50% 65% Non Payable Non Payable 51941482 CLINIC CMPLX RPR S/A/L + 5 CM/> EACH 13122 $305.00 510 $213.50 $152.50 $244.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945699 CLINIC CNTRL NOSEBLEED ANT CPLX EACH 30903 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51945707 CLINIC CNTRL NOSEBLEED POST INIT EACH 30905 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51945715 CLINIC CNTRL NOSEBLEED SUBSEQ EACH 30906 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951820 CLINIC CNTRLHEMORRNASOPHARSMP EACH 42970 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951812 CLINIC CNTRLHEMORROROPHARYSMP EACH 42960 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946291 CLINIC COLONOSCOPY W/LESION REM EACH 45385 "$2,918.00 " 510 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947075 CLINIC COLOPERINEOR NON-OB EACH 57210 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947067 CLINIC COLPORRHAPHY NON-OB EACH 57200 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947125 CLINIC COLPOSC BX&CURETTAGE EACH 57454 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51947133 CLINIC COLPOSC CERV BX EACH 57455 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51947117 CLINIC COLPOSC CERVIX/VAG EACH 57452 $493.00 510 $345.10 $246.50 $394.40 65% 80% 50% 50% 65% Non Payable Non Payable 51947141 CLINIC COLPOSC CURETTAGE EACH 57456 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51947091 CLINIC COLPOSC VAGINA ALL EACH 57420 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51947109 CLINIC COLPOSC VAGINA BX EACH 57421 "$1,988.00 " 510 "$1,391.60 " $994.00 "$1,590.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946994 CLINIC COLPOSCOPY W/BX VULVA EACH 56821 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51947166 CLINIC COLPOSCOPY W/CONIZ CERVIX EACH 57461 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948941 CLINIC COMPLEX RET DETACH EACH 67113 "$12,923.00 " 510 "$9,046.10 " "$6,461.50 " "$10,338.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941789 CLINIC COMPOSITE SKIN GRAFT EACH 15760 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947208 CLINIC CONE CERVIX KNIFE/LASER EACH 57520 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947216 CLINIC CONE CERVIX LOOP ELECT EXC EACH 57522 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952257 CLINIC CONSULTATIONLVL2 EACH 99242 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51952265 CLINIC CONSULTATIONLVL3 EACH 99243 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51952273 CLINIC CONSULTATIONLVL4 EACH 99244 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51952281 CLINIC CONSULTATIONLVL5 EACH 99245 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51942670 CLINIC CONTOUR FACE BONE LESION EACH 21029 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51919694 CLINIC COPD EDUCATION-GROUP 2-4 EACH 98961 $72.00 942 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919702 CLINIC COPD EDUCATION-GROUP 5-8 EACH 98962 $48.00 942 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919686 CLINIC COPD EDUCATION-INDIVIDUAL EACH 98960 $96.00 942 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51944445 CLINIC CORRECT BUN DBL OSTEOTMY EACH 28299 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944437 CLINIC CORRECT BUN PHALNX OSTETMY EACH 28298 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944429 CLINIC CORRECT BUNION (LAPIDUS) EACH 28297 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944403 CLINIC CORRECT BUN-KELLER/MCB/MAY EACH 28292 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944411 CLINIC CORRECT BUN-MITCHELL/CHEVR EACH 28296 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51918720 CLINIC COV19 VAC ADMIN EACH 90480 $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51952620 CLINIC CPLX CHRNC CARE 1ST 60 MIN EACH 99487 $395.00 510 $276.50 $197.50 $316.00 65% 80% 50% 50% 65% Non Payable Non Payable 51952638 CLINIC CPLX CHRNC CARE EA ADDL 30 EACH 99489 $68.00 510 $47.60 $34.00 $54.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952950 CLINIC CPLX CHRNC CARE EA ADDL 30 EACH 99439 $99.00 510 $69.30 $49.50 $79.20 65% 80% 50% 50% 65% Non Payable Non Payable 51949592 CLINIC CREATE TEAR DUCT DRAIN EACH 68750 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952141 CLINIC CREATEEARDRUMOPENING EACH 69436 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945525 CLINIC CR-REM/BIV BOOT/BODY CST EACH 29700 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945558 CLINIC CR-REPAIR SPICA/MIN/RISS EACH 29720 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945541 CLINIC CR-RMVL/BIV SPICA/MIN/RISS EACH 29710 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945475 CLINIC CR-STRAPPING ANKLE/FOOT EACH 29540 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945319 CLINIC CR-STRAPPING SHOULDER EACH 29240 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51945574 CLINIC CR-WEDGING CAST NOT CLUBFT EACH 29740 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945582 CLINIC CR-WEDGING CLUBFOOT CAST EACH 29750 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51946788 CLINIC CRYOSURGERY PENIS LES EACH 54056 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942274 CLINIC CRYOTHERAPY ACNE EACH 17340 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51947182 CLINIC CURETTAGE ENDOCERVICAL EACH 57505 "$1,988.00 " 510 "$1,391.60 " $994.00 "$1,590.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946663 CLINIC CYSTOMETROGRAM W/VP&UP EACH 51729 "$1,689.00 " 510 "$1,182.30 " $844.50 "$1,351.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946655 CLINIC CYSTOMETROGRAM/CMG CPLX EACH 51726 $612.00 510 $428.40 $306.00 $489.60 65% 80% 50% 50% 65% Non Payable Non Payable 51951903 CLINIC CYSTOMETROGRAMW/UP EACH 51727 "$1,689.00 " 510 "$1,182.30 " $844.50 "$1,351.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946697 CLINIC CYSTOSCOPY EACH 52000 "$1,689.00 " 510 "$1,182.30 " $844.50 "$1,351.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946713 CLINIC CYSTOSCOPY EACH 52281 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946739 CLINIC CYSTOSCOPY AND TREATMENT EACH 52315 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946721 CLINIC CYSTOSCOPY W REM STENT/FB EACH 52310 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946747 CLINIC CYSTOSCOPY W/STENT INS EACH 52332 "$8,620.00 " 510 "$6,034.00 " "$4,310.00 " "$6,896.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951945 CLINIC CYSTOSCOPYCHEMODENERVATION EACH 52287 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946705 CLINIC CYSTOURETHROSCOPY W BX EACH 52204 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947240 CLINIC D&C NON-OB EACH 58120 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940286 CLINIC DEB BONE 20 SQ CM/< EACH 11044 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940310 CLINIC DEB BONE ADD-ON EACH 11047 $845.00 510 $591.50 $422.50 $676.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940302 CLINIC DEB MUSC/FASCIA ADD-ON EACH 11046 $305.00 510 $213.50 $152.50 $244.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940260 CLINIC DEB SUBQ TISSUE 20 SQ CM/< EACH 11042 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51940294 CLINIC DEB SUBQ TISSUE ADD-ON EACH 11045 $195.00 510 $136.50 $97.50 $156.00 65% 80% 50% 50% 65% Non Payable Non Payable 51949717 CLINIC DEBR MASTOID CAVITY SMP EACH 69220 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940955 CLINIC DEBR NAIL(S) 6 OR MORE EACH 11721 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51940948 CLINIC DEBR NAIL(S) UP TO 5 EACH 11720 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51949956 CLINIC DEBR OPEN WOUND 1 20 CM/< EACH 97597 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51949964 CLINIC DEBR OPEN WOUND ADDL 20CM EACH 97598 $258.00 510 $180.60 $129.00 $206.40 65% 80% 50% 50% 65% Non Payable Non Payable 51940252 CLINIC DEBRIDE SKIN BONE FX SITE EACH 11012 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940245 CLINIC DEBRIDE SKIN MUSC FX SITE EACH 11011 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941771 CLINIC DELAY FLAP EYE/NOS/EAR/LIP EACH 15630 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951077 CLINIC DERMABRASION EACH 15780 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941821 CLINIC DERMABRASION NOT FACE EACH 15782 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941813 CLINIC DERMABRASION SEG FACE EACH 15781 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941839 CLINIC DERMABRASION SUPERFICIAL EACH 15783 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942027 CLINIC DEST BENIGN LESION <15 EACH 17110 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51948628 CLINIC DEST LES CORNEA CRYO/PHOTO EACH 65450 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942167 CLINIC DEST LES FACE/EAR TO 0.5CM EACH 17280 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942043 CLINIC DEST LES MAL T/A TO 0.5CM EACH 17260 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942100 CLINIC DEST LES SCLP/HEAD TO0.5CM EACH 17270 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941995 CLINIC DEST LESN BGN/PREMALG 2-14 EACH 17003 $76.00 510 $53.20 $38.00 $60.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942175 CLINIC DEST LESN FACE/EAR .6-1.0 EACH 17281 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942183 CLINIC DEST LESN FACE/EAR 1.1-2.0 EACH 17282 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942191 CLINIC DEST LESN FACE/EAR 2.1-3.0 EACH 17283 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942209 CLINIC DEST LESN FACE/EAR 3.1-4.0 EACH 17284 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942217 CLINIC DEST LESN MAL FACE/EAR >4 EACH 17286 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946762 CLINIC DEST LESN PENIS SMP CHEM EACH 54050 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942001 CLINIC DEST LESN PREMAL 15+ LS EACH 17004 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941987 CLINIC DEST LESN PREMALIG 1ST LES EACH 17000 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942118 CLINIC DEST LESN SCLP/HEAD .6-1.0 EACH 17271 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942159 CLINIC DEST LESN SCLP/HEAD>4.0CM EACH 17276 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942126 CLINIC DEST LESN SCLP/HEAD1.1-2.0 EACH 17272 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942134 CLINIC DEST LESN SCLP/HEAD2.1-3.0 EACH 17273 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942142 CLINIC DEST LESN SCLP/HEAD3.1-4.0 EACH 17274 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942076 CLINIC DEST LESN TRNK/ARM 2.1-3.0 EACH 17263 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942084 CLINIC DEST LESN TRNK/ARM 3.0-4.0 EACH 17264 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942092 CLINIC DEST LESN TRUNK/ARM >4.0CM EACH 17266 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51947000 CLINIC DEST LESN VAGINA SMP EACH 57061 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942019 CLINIC DEST LESN VASCULAR <10CM EACH 17106 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51948396 CLINIC DEST NRV HYPOGASTRIC PLEX EACH 64681 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948230 CLINIC DEST NRV INTERCOSTAL EACH 64620 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951176 CLINIC DESTBENIGNLESIONS15+ EACH 17111 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951168 CLINIC DESTLESNVASCULAR>50CM EACH 17108 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951150 CLINIC DESTLESNVASCULAR10-50CM EACH 17107 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947018 CLINIC DESTROY VAG LESIONS COMPL EACH 57065 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946945 CLINIC DESTROY VULVA LES COMPL EACH 56515 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946937 CLINIC DESTROY VULVA LESIONS SIM EACH 56501 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946333 CLINIC DESTRUCT LES ANUS SURG EXC EACH 46220 "$2,918.00 " 510 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942068 CLINIC DESTRUCT SKIN LESION .1-2 EACH 17262 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942050 CLINIC DESTRUCT SKIN LESION .6-.1 EACH 17261 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51946440 CLINIC DESTRUCTION ANAL LESION(S) EACH 46900 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51946770 CLINIC DESTRUCTION PENIS LES EACH 54055 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51919728 CLINIC DIABETES EDUCATION-GROUP 2-4 EACH 98961 $72.00 942 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919736 CLINIC DIABETES EDUCATION-GROUP 5-8 EACH 98962 $48.00 942 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919710 CLINIC DIABETES EDUCATION-INDIVIDUAL EACH 98960 $96.00 942 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51946366 CLINIC DIAGNOSTIC ANOSCOPY EACH 46600 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51946283 CLINIC DIAGNOSTIC COLONOSCOPY EACH 45378 "$2,260.00 " 510 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945806 CLINIC DIAGNOSTIC LARYNGOSCOPY EACH 31575 $490.00 510 $343.00 $245.00 $392.00 65% 80% 50% 50% 65% Non Payable Non Payable 51946267 CLINIC DIAGNOSTIC SIGMOIDOSCOPY EACH 45330 "$2,260.00 " 510 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949659 CLINIC DRAIN ABSC EXT AUD CANAL EACH 69020 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946044 CLINIC DRAIN ABSC/CYST MOUTH SMP EACH 40800 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945608 CLINIC DRAIN ABSC/HEMAT NASAL EACH 30000 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% Non Payable Non Payable 51949642 CLINIC DRAIN EXTERNAL EAR LESION EACH 69000 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943108 CLINIC DRAIN FINGER ABSCESS EACH 26010 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51943355 CLINIC DRAIN LOWER LEG LES DEEP EACH 27603 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51921278 CLINIC DRAIN MOUTH LES SUBMANDIBUL EACH 41017 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51921260 CLINIC DRAIN MOUTH LES SUBMENTAL EACH 41016 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945616 CLINIC DRAIN NOSE LESION EACH 30020 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946176 CLINIC DRAIN SALIVARY GLAND EACH 42310 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942563 CLINIC DRAIN/INJ MED JT/BURSA US EACH 20606 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942548 CLINIC DRAIN/INJ SM JT/BURSA W/US EACH 20604 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 51951770 CLINIC DRAINABSCSUBMAXILLARYEXT EACH 42320 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946127 CLINIC DRAINAGE OF GUM LESION EACH 41800 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51946838 CLINIC DRAINAGE OF SCROTUM EACH 54700 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951754 CLINIC "DRAINAGELYMPHNODE,EXT " EACH 38305 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951747 CLINIC "DRAINAGELYMPHNODE,SIMPLE " EACH 38300 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941961 CLINIC DRESS/DEB BURN <5% TOTAL EACH 16020 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941979 CLINIC DRESS/DEB BURN 5-10% EACH 16025 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941920 CLINIC DRESSING CHANGE W/ANES EACH 15852 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948248 CLINIC DSTR NULYT AGT GNCLR NRV EACH 64624 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51906212 CLINIC DUODENAL MOTILITY STUDY EACH 91022 "$1,326.00 " 920 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51945988 CLINIC DX BONE MARROW BX EACH 38222 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51920809 CLINIC DX BRONCHOSCOPE/CELL WASHING EACH 31622 "$4,197.00 " 510 "$2,937.90 " "$2,098.50 " "$3,357.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51920817 CLINIC DX BRONCHOSCOPE/LAVAGE EACH 31624 "$4,197.00 " 510 "$2,937.90 " "$2,098.50 " "$3,357.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949097 CLINIC ELYELID DRAIN ABSCESS EACH 67700 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51945731 CLINIC ENDO NASAL DIAGNOSTIC EACH 31231 $490.00 510 $343.00 $245.00 $392.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945749 CLINIC ENDO NASAL DX W/MAX SINUSC EACH 31233 "$1,010.00 " 510 $707.00 $505.00 $808.00 65% 80% 50% 50% 65% Non Payable Non Payable 51947232 CLINIC ENDOMET BIOP W/COLPO EACH 58110 $632.00 510 $442.40 $316.00 $505.60 65% 80% 50% 50% 65% Non Payable Non Payable 51947448 CLINIC EPIDURL LYSIS SINGLE DAY EACH 62264 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51921328 CLINIC ERCP DUCT STENT PLACEMENT EACH 43274 "$14,092.00 " 750 "$9,864.40 " "$7,046.00 " "$11,273.60 " 65% 80% Covered Charges NTE $1501/case "$1,023 " $930 $467.71 "$2,526 " "$2,526 " 51921336 CLINIC ERCP REMOVE FORGN BODY DUCT EACH 43275 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% Covered Charges NTE $1501/case "$1,023 " $930 $380.18 "$2,526 " "$2,526 " 51921310 CLINIC ERCP W/RETROGRADE REMOVAL EACH 43264 "$9,470.00 " 750 "$6,629.00 " "$4,735.00 " "$7,576.00 " 65% 80% Covered Charges NTE $1501/case "$1,023 " $930 $366.52 "$1,113 " "$1,113 " 51906196 CLINIC ESOPHAGUS MOTILITY STUDY EACH 91010 "$1,326.00 " 750 $928.20 $663.00 "$1,060.80 " 65% 80% Covered Charges NTE $1501/case $88 $80 $197.64 Non Payable Non Payable 51906204 CLINIC ESOPHGL MOTIL W/STIM/PERFUS EACH 91013 $714.00 920 $499.80 $357.00 $571.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51942977 CLINIC EX ARM/ELBOW TUM DEEP < 5 EACH 24076 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946986 CLINIC EXAM OF VULVA W/SCOPE EACH 56820 $493.00 510 $345.10 $246.50 $394.40 65% 80% 50% 50% 65% Non Payable Non Payable 51942878 CLINIC EXC ABD LES SC < 3 CM EACH 22902 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942969 CLINIC EXC ARM/ELBW LES SC < 3 CM EACH 24075 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942951 CLINIC EXC ARM/ELBW LES SC 3 CM/> EACH 24071 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942829 CLINIC EXC BACK LES SC < 3 CM EACH 21930 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943397 CLINIC EXC BACK TUM DEEP < 5 CM EACH 27615 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942845 CLINIC EXC BACK TUM DEEP 5 CM/> EACH 21933 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942340 CLINIC EXC BREAST CYST/FIBRO/TUM EACH 19120 "$9,425.00 " 510 "$6,597.50 " "$4,712.50 " "$7,540.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941052 CLINIC EXC CYST PILONIDAL CPLX EACH 11772 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942647 CLINIC EXC FACE LES SBQ 2 CM/> EACH 21012 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942639 CLINIC EXC FACE LES SC <2 CM EACH 21011 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942654 CLINIC EXC FACE TUM DEEP < 2 CM EACH 21013 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942662 CLINIC EXC FACE TUM DEEP 2 CM/> EACH 21014 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943843 CLINIC EXC FOOT TEND SHEATH EXT EACH 28088 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943686 CLINIC EXC FOOT/TOE TUM 1.5 CM/> EACH 28039 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943017 CLINIC EXC FOREARM LES SC < 3 CM EACH 25075 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943009 CLINIC EXC FOREARM TUM DEEP>3CM EACH 25073 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943835 CLINIC EXC FT TENDON SHEATH FLEX EACH 28086 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943710 CLINIC EXC FT/TOE TUM DEEP <1.5CM EACH 28045 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943694 CLINIC EXC FT/TOE TUM DEP 1.5CM/> EACH 28041 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943702 CLINIC EXC FT/TOE TUM SC < 1.5 CM EACH 28043 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943132 CLINIC EXC HAND LES SC 1.5 CM/> EACH 26111 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940815 CLINIC EXC H-F-NK-SP MAL+MARG 0.5 EACH 11620 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943272 CLINIC EXC HIP/PELVIC LES <3CM EACH 27047 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943413 CLINIC EXC LEG/ANKLE TUM<3CM EACH 27618 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940567 CLINIC EXC LES BGN TRK/ARM TO .5C EACH 11400 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940872 CLINIC EXC LES MAL FACE/EAR .5 CM EACH 11640 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940765 CLINIC EXC LES MAL TRK/ARM .6-1CM EACH 11601 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946135 CLINIC EXC LESION DENTOALVEOLAR EACH 41825 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940575 CLINIC EXC LESN BGN T/ARM .6-1CM EACH 11401 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51940617 CLINIC EXC LESN BGN T/ARM >4.0CM EACH 11406 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940583 CLINIC EXC LESN BGN T/ARM 1.1-2.0 EACH 11402 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940591 CLINIC EXC LESN BGN T/ARM 2.1-3.0 EACH 11403 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940609 CLINIC EXC LESN BGN T/ARM 3.1-4.0 EACH 11404 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948560 CLINIC EXC LESN CORNEA EACH 65400 "$2,504.00 " 510 "$1,752.80 " "$1,252.00 " "$2,003.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940922 CLINIC EXC LESN FACE/EAR >4.0 CM EACH 11646 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940906 CLINIC EXC LESN FACE/EAR 2.1-3.0 EACH 11643 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940914 CLINIC EXC LESN FACE/EAR 3.1-4.0 EACH 11644 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940880 CLINIC EXC LESN MAL FACE .6-1.0CM EACH 11641 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940807 CLINIC EXC LESN TRUNK/ARM >4.0 CM EACH 11606 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942787 CLINIC EXC NECK LES SC < 3 CM EACH 21555 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942779 CLINIC EXC NECK LES SC 3 CM/> EACH 21552 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942795 CLINIC EXC NECK TUM DEEP < 5 CM EACH 21556 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948586 CLINIC EXC PTERYGIUM W/O GRAFT EACH 65420 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940823 CLINIC EXC S/N/H/F/G MAL+ .6-1 EACH 11621 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940864 CLINIC EXC S/N/H/F/G MAL+ >4 CM EACH 11626 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940849 CLINIC EXC S/N/H/F/G MAL+ 2.1-3 EACH 11623 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940856 CLINIC EXC S/N/H/F/G MAL+ 3.1-4 EACH 11624 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942894 CLINIC EXC SHOULDER LES SC < 3 CM EACH 23075 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942886 CLINIC EXC SHOULDER LES SC 3 CM+ EACH 23071 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943314 CLINIC EXC THIGH/KNEE LES SC < 3 EACH 27327 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51921245 CLINIC EXC THIGH/KNEE LES SC 3+CM EACH 27337 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946119 CLINIC EXC TONGUE LES W/CLOSURE EACH 41112 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946101 CLINIC EXC TONGUE LES WO CLOSURE EACH 41110 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940781 CLINIC EXC TR-EXT MAL+MARG 2.1-3 EACH 11603 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940799 CLINIC EXC TR-EXT MAL+MARG 3.1-4 EACH 11604 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941946 CLINIC EXC ULCER COCCYGEAL EACH 15920 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948594 CLINIC EXC/TRANS PTERYGIUM W/GRFT EACH 65426 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951655 CLINIC EXCCYSTDERMOIDSUBQ EACH 30124 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51950988 CLINIC EXCCYSTPILONIDALEXTEN EACH 11771 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951374 CLINIC EXCHANDLESSC<1.5CM EACH 27630 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946143 CLINIC EXCISE GUM LESION EACH 41826 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942704 CLINIC EXCISE MANDIBLE LESION EACH 21040 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942688 CLINIC EXCISE ZYGOMA TUMOR EACH 21030 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946077 CLINIC EXCISE/REPAIR MOUTH LESION EACH 40812 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942837 CLINIC EXCISION BACK LES SC 3 CM+ EACH 21931 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946978 CLINIC EXCISION BARTHOLIN'S GLAND EACH 56740 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942803 CLINIC EXCISION CHEST WALL TUMOR EACH 21601 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951382 CLINIC EXCLEG/ANKLELESSC3CM/> EACH 27632 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951366 CLINIC EXCLEG/ANKLETUMDEEP<5 EACH 27619 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951390 CLINIC EXCLEG/ANKLETUMDEEP5+ EACH 27634 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943306 CLINIC EXPLORATION OF KNEE JOINT EACH 27310 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945756 CLINIC EXPLORE MAXILLARY SINUS EACH 31256 "$9,260.00 " 510 "$6,482.00 " "$4,630.00 " "$7,408.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942449 CLINIC EXPLORE WOUND ABDOMEN EACH 20102 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942456 CLINIC EXPLORE WOUND EXTREMITY EACH 20103 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943124 CLINIC EXPLORE/TREAT FINGER JOINT EACH 26075 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943322 CLINIC EXPLORE/TREAT KNEE JOINT EACH 27331 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952125 CLINIC EXPRSSFOLLICLECONJUNCT EACH 68040 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51948818 CLINIC EXTRACT LENS EACH 66940 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952059 CLINIC FETALCORDPUNCTPRENATAL EACH 59012 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51952067 CLINIC FETALSHUNTPLACEMENTW/US EACH 59076 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51907731 CLINIC FIBROSCAN EACH 91200 $387.00 402 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $110.68 $110.68 $36.52 Non Payable Non Payable 51948727 CLINIC FISTULIZATION OF SCLERA EACH 66170 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947059 CLINIC FITTING DIAPHAGM/CERV CAP EACH 57170 $493.00 510 $345.10 $246.50 $394.40 65% 80% 50% 50% 65% Non Payable Non Payable 51947042 CLINIC FITTING/INSERTION PESSARY EACH 57160 $493.00 510 $345.10 $246.50 $394.40 65% 80% 50% 50% 65% Non Payable Non Payable 51904811 CLINIC FLU VACCINE 3 YRS & > IM EACH 90658 $15.00 636 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 51904829 CLINIC FLU VACCINE NO PRESERC 3 & > EACH 90656 $15.00 636 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 51940005 CLINIC FNA BX W/O IMG GDN EA ADDL EACH 10004 $813.00 510 $569.10 $406.50 $650.40 65% 80% 50% 50% 65% Non Payable Non Payable 51940054 CLINIC FNA W CT GUIDE - 1ST EACH 10009 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940062 CLINIC FNA W CT GUIDE EA ADDL EACH 10010 $363.00 510 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% Non Payable Non Payable 51940039 CLINIC FNA W FLUORO GUIDE - 1ST EACH 10007 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940047 CLINIC FNA W FLUORO GUIDE EA ADDL EACH 10008 $363.00 510 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% Non Payable Non Payable 51940070 CLINIC FNA W MR GUIDE - 1ST EACH 10011 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940088 CLINIC FNA W MR GUIDE EA ADDL EACH 10012 $363.00 510 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% Non Payable Non Payable 51940013 CLINIC FNA W US GUIDE - 1ST EACH 10005 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940021 CLINIC FNA W US GUIDE EA ADDL EACH 10006 $363.00 510 $254.10 $181.50 $290.40 65% 80% 50% 50% 65% Non Payable Non Payable 51948735 CLINIC FOLLOW-UP SURGERY OF EYE EACH 66250 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941706 CLINIC FULL GRAFT + 20CM N/E/E/L EACH 15261 $880.00 510 $616.00 $440.00 $704.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941680 CLINIC FULL GRAFT +20CM F/C/M/H/F EACH 15241 $880.00 510 $616.00 $440.00 $704.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945160 CLINIC FUSION BIG TOE JOINT-JONES EACH 28760 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945152 CLINIC FUSION BIG TOE JT-INTRPHLN EACH 28755 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945145 CLINIC FUSION BIG TOE JT-MTTRSPHN EACH 28750 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945079 CLINIC FUSION FOOT BONES-PANTALAR EACH 28705 "$46,078.00 " 510 "$32,254.60 " "$23,039.00 " "$36,862.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945137 CLINIC FUSION FOOT BONES-SNGL JT EACH 28740 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945103 CLINIC FUSION FT BONES MULT/TRANS EACH 28730 "$32,541.00 " 510 "$22,778.70 " "$16,270.50 " "$26,032.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945111 CLINIC FUSION FT BONES W/OSTEOTMY EACH 28735 "$32,541.00 " 510 "$22,778.70 " "$16,270.50 " "$26,032.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943215 CLINIC FUSION OF FINGER TENDONS EACH 26474 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945087 CLINIC FUSION OF FOOT BONES EACH 28715 "$32,541.00 " 510 "$22,778.70 " "$16,270.50 " "$26,032.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945095 CLINIC FUSION OF FT BONES-ANTHROD EACH 28725 "$32,541.00 " 510 "$22,778.70 " "$16,270.50 " "$26,032.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944353 CLINIC FUSION OF TOES EACH 28280 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51950020 CLINIC FXJL ABL LSR 1ST 100 SQ CM EACH 0479T "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952174 CLINIC GLUCMONITORCONTPHYSI&R EACH 95251 $115.00 510 $80.50 $57.50 $92.00 65% 80% 50% 50% 65% Non Payable Non Payable 51952166 CLINIC GLUCOSEMONITORINGCONT EACH 95250 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51941797 CLINIC GRAFT HAIR 1-15 PNCH EACH 15775 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941805 CLINIC GRAFT HAIR TRNSPL >15 PNCH EACH 15776 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941656 CLINIC GRAFT PINCH SGL/MUL TO 2CM EACH 15050 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946341 CLINIC HEMORRHOIDECTOMY SMP EACH 46221 "$2,260.00 " 510 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941128 CLINIC HORMONE PELLET IMPLANT EACH 11980 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51946929 CLINIC HYMENECTOMY SINGLE INC EACH 56442 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947315 CLINIC HYSTEROSCOPY DX SEP PROC EACH 58555 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947331 CLINIC HYSTEROSCOPY REMOVE FB EACH 58562 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947349 CLINIC HYSTEROSCOPY STERILIZAT EACH 58565 "$12,298.00 " 510 "$8,608.60 " "$6,149.00 " "$9,838.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947323 CLINIC HYSTERSC BX ENDOMET EACH 58558 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946218 CLINIC "I & D, ABSCESS, PERITONS " EACH 42700 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% Non Payable Non Payable 51946895 CLINIC I&D ABSC GLAND BARTHOLIN'S EACH 56420 $493.00 510 $345.10 $246.50 $394.40 65% 80% 50% 50% 65% Non Payable Non Payable 51946887 CLINIC I&D ABSC VULVA/PERINEAL EACH 56405 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943579 CLINIC I&D BURSA FOOT EACH 28001 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940203 CLINIC I&D WOUND POST OP CPLX EACH 10180 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946259 CLINIC "I&D, ISCHI/PERI RECTAL ABC " EACH 45005 "$2,918.00 " 510 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951762 CLINIC I&DABSCSUBLINGEXTRAORAL EACH 41015 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952133 CLINIC I&DGLANDLACRIMAL EACH 68400 "$2,504.00 " 510 "$1,752.80 " "$1,252.00 " "$2,003.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51904365 CLINIC IMMUN ADM 1 VAC ORAL/NASAL EACH 90473 $175.00 771 $122.50 $87.50 $140.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51904373 CLINIC IMMUN ADM VAC ORAL/NASAL EA AD EACH 90474 $23.87 771 $16.71 $11.94 $19.10 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51903706 CLINIC IMMUN ADMIN VAC IM/SQ EA AD EACH 90472 $10.00 771 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51947646 CLINIC IMP PUMP ANAYSIS W/REPG EACH 62369 $739.00 510 $517.30 $369.50 $591.20 65% 80% 50% 50% 65% Non Payable Non Payable 51947661 CLINIC IMPLANT ELECTRODE - 1 LEAD EACH 63650 "$16,910.00 " 510 "$11,837.00 " "$8,455.00 " "$13,528.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948149 CLINIC IMPLANT NEUROELECTRODES EACH 64555 "$16,910.00 " 510 "$11,837.00 " "$8,455.00 " "$13,528.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943181 CLINIC IMPLANT REMOVE FINGER/HAND EACH 26320 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947612 CLINIC IMPLANT SPINE INF PUMP EACH 62362 "$44,096.00 " 510 "$30,867.20 " "$22,048.00 " "$35,276.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944528 CLINIC INC OF METATARSAL (NOT 1) EACH 28308 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944247 CLINIC "INC OF TOE TENDON, SINGLE " EACH 28232 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943116 CLINIC INCISE FINGER TEND SHEATH EACH 26055 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948685 CLINIC INCISE INNER EYE ADHESIONS EACH 65860 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951887 CLINIC INCISE&DRAINBLADDER EACH 51040 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944494 CLINIC INCISE/GRAFT MIDFOOT BONES EACH 28305 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943363 CLINIC INCISION ACHILLES TENDON EACH 27605 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944254 CLINIC INCISION EXTENSOR TENDON EACH 28234 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944239 CLINIC INCISION FLEXOR TENDON(S) EACH 28230 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944536 CLINIC INCISION METATAR (SWANSON) EACH 28309 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944510 CLINIC INCISION METATAR-1 W/GRAFT EACH 28307 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944502 CLINIC INCISION METATARSAL - 1ST EACH 28306 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946317 CLINIC INCISION OF ANAL ABSCESS EACH 46050 "$2,260.00 " 510 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944478 CLINIC INCISION OF ANKLE BONE EACH 28302 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943611 CLINIC INCISION OF FOOT FASCIA EACH 28008 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944452 CLINIC INCISION OF HEEL BONE EACH 28300 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944486 CLINIC INCISION OF MIDFOOT BONES EACH 28304 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946325 CLINIC INCISION OF RECTAL ABSCESS EACH 46060 "$6,943.00 " 510 "$4,860.10 " "$3,471.50 " "$5,554.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943629 CLINIC INCISION OF TOE TENDON EACH 28010 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943637 CLINIC INCISION OF TOE TENDONS EACH 28011 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946309 CLINIC INCISION RECTAL ABSCESS EACH 46040 "$2,918.00 " 510 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940161 CLINIC INCISION/REM FB SUBQ SMP EACH 10120 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51940393 CLINIC INCISIONAL SKIN BIOPSY 1ST EACH 11106 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940419 CLINIC INCISIONAL SKIN BIOPSY ADD EACH 11107 $197.00 510 $137.90 $98.50 $157.60 65% 80% 50% 50% 65% Non Payable Non Payable 51947414 CLINIC INDUCED ABORTION BY D EVAC EACH 59841 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947901 CLINIC INJ AA/STRD GNCLR NERVE EACH 64454 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948107 CLINIC INJ ANES GANGLION STELLATE EACH 64510 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948115 CLINIC INJ ANES HYPOGASTRC PLEXUS EACH 64517 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947786 CLINIC INJ ANES NERVE INTERC SGL EACH 64420 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943280 CLINIC INJ ARTHROGRAM HIP W/O EACH 27093 $760.00 510 $532.00 $380.00 $608.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942480 CLINIC INJ CARPAL TUNNEL LT EACH 20526 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 51941078 CLINIC INJ INTRALESNAL >7 LESNS EACH 11901 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941060 CLINIC INJ INTRALESNAL TO 7 LESNS EACH 11900 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51947489 CLINIC INJ NEUROLYTIC SUBARACH EACH 62280 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945889 CLINIC INJ SCLERO SOLN VEIN MULTI EACH 36471 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51945871 CLINIC INJ SCLERO SOLN VEIN SGL EACH 36470 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942506 CLINIC INJ SGL TEND ORIGIN/INSERT EACH 20551 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 51941086 CLINIC INJ SQ FILL MAT UP TO 1CC EACH 11950 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51949485 CLINIC INJ SUBCONJUNCTIVAL EACH 68200 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941094 CLINIC INJ SUBQ FILL MAT 1.1-5.0 EACH 11951 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941102 CLINIC INJ SUBQ FILL MAT>10CC EACH 11954 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947596 CLINIC INJ(S) SPINE W/CATH L/S EACH 62327 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951259 CLINIC INJARTHROGRAMELBOW EACH 24220 $760.00 510 $532.00 $380.00 $608.00 65% 80% 50% 50% 65% Non Payable Non Payable 51947588 CLINIC INJE SPINE W/CATH C/T EACH 62325 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946358 CLINIC INJECT INTO HEMORRHOID(S) EACH 46500 "$2,260.00 " 510 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948180 CLINIC INJECTION TREATMENT NERVE EACH 64610 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947554 CLINIC INJECTION(S) SPINE C/T EACH 62321 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947570 CLINIC INJECTION(S) SPINE L/S EACH 62323 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952489 CLINIC INJEPIDURW/USCER/THOR+ EACH 0229T $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952471 CLINIC INJEPIDURW/USCER/THOR1 EACH 0228T $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952497 CLINIC INJEPIDURW/USLUMB/SAC1 EACH 0230T $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952505 CLINIC INJEPIDURW/USLUMB/SC+ EACH 0231T $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952422 CLINIC INJPARAVERTW/USCER/THR2 EACH 0214T $838.00 510 $586.60 $419.00 $670.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952430 CLINIC INJPARAVERTW/USCER/THR3 EACH 0215T $410.00 510 $287.00 $205.00 $328.00 65% 80% 50% 50% 65% Non Payable Non Payable 51952448 CLINIC INJPARAVERTW/USLUMB/SC1 EACH 0216T "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952455 CLINIC INJPARAVERTW/USLUMB/SC2 EACH 0217T $838.00 510 $586.60 $419.00 $670.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952463 CLINIC INJPARAVERTW/USLUMB/SC3 EACH 0218T $410.00 510 $287.00 $205.00 $328.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951838 CLINIC INJPROLAPSCLERO/PERIRECT EACH 45520 "$2,260.00 " 510 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951028 CLINIC INJSUBQFILLMATER5.0-10 EACH 11952 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941136 CLINIC INS IMPL DRUG DEL NON-BIO EACH 11981 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51947273 CLINIC INS INTRAUTERINE DEVICE EACH 58300 $25.00 510 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945913 CLINIC INSJ PICC RS&I 5 YR+ EACH 36573 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947695 CLINIC INSRT/REDO SPINE N GEN EACH 63685 "$76,777.00 " 510 "$53,743.90 " "$38,388.50 " "$61,421.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946648 CLINIC INSTILL ANTICARCIN BLADDER EACH 51720 "$1,689.00 " 510 "$1,182.30 " $844.50 "$1,351.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941425 CLINIC INTMD RPR FACE/MM >30.0 CM EACH 12057 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941409 CLINIC INTMD RPR FACE/MM 12.6-20 EACH 12055 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941417 CLINIC INTMD RPR FACE/MM 20.1-30 EACH 12056 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51952026 CLINIC INTROHEMOSTATICAGNT/PACK EACH 57180 $493.00 510 $345.10 $246.50 $394.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952018 CLINIC IRRIG/APPLMEDICMENTVAGINA EACH 57150 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51946598 CLINIC IRRIGATION OF BLADDER EACH 51700 $612.00 510 $428.40 $306.00 $489.60 65% 80% 50% 50% 65% Non Payable Non Payable 51951135 CLINIC IVAGENTCKVASCFLOWFLAP EACH 15860 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51925048 CLINIC J&J COV19 VAC ADMIN BOOSTER EACH 0034A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51919223 CLINIC J&J COVID VAC ADM-SINGLE DOSE EACH 0031A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51942589 CLINIC JT INJ - MAJOR W/US EACH 20611 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 51948644 CLINIC KERATPLASTY PENETRAT EACH 65730 "$10,053.00 " 510 "$7,037.10 " "$5,026.50 " "$8,042.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948651 CLINIC KERATPLASTY PENETRAT PSEUD EACH 65755 "$10,053.00 " 510 "$7,037.10 " "$5,026.50 " "$8,042.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941433 CLINIC LAC CPLX TRUNK 1.1-2.5CM EACH 13100 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947307 CLINIC LAPARO VAG HYSTERECTOMY EACH 58550 "$14,267.00 " 510 "$9,986.90 " "$7,133.50 " "$11,413.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952034 CLINIC LAPAROOVIDUCT-OVARYNOS EACH 58679 "$14,267.00 " 510 "$9,986.90 " "$7,133.50 " "$11,413.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951663 CLINIC LARGSCW/LASERDSTRLESUNI EACH 31572 "$9,260.00 " 510 "$6,482.00 " "$4,630.00 " "$7,408.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945798 CLINIC LARYNGOSCOPY FOR ASP EACH 31515 "$1,010.00 " 510 $707.00 $505.00 $808.00 65% 80% 50% 50% 65% Non Payable Non Payable 51948883 CLINIC LASER SURGERY EYE STRANDS EACH 67031 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949907 CLINIC LASER TX SKIN < 250 SQ CM EACH 96920 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51949923 CLINIC LASER TX SKIN >500 SQ CM EACH 96922 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51949915 CLINIC LASER TX SKIN 250-500 SQ C EACH 96921 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941557 CLINIC LATE CLOSURE OF WOUND EACH 13160 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942738 CLINIC LATERAL CANTHOPEXY EACH 21282 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940682 CLINIC LES BGN FACE/EAR TO 0.5CM EACH 11440 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940625 CLINIC LES BGN SCALP/HND TO .5CM EACH 11420 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940757 CLINIC LES MAL TRUNK/ARM TO 0.5CM EACH 11600 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940690 CLINIC LESN BGN FACE/EAR .6-1.0CM EACH 11441 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940732 CLINIC LESN BGN FACE/EAR > 4.0 CM EACH 11446 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940708 CLINIC LESN BGN FACE/EAR 1.1-2.0 EACH 11442 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940716 CLINIC LESN BGN FACE/EAR 2.1-3.0 EACH 11443 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940724 CLINIC LESN BGN FACE/EAR 3.1-4.0 EACH 11444 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940674 CLINIC LESN BGN SCALP/HND >4.0CM EACH 11426 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940641 CLINIC LESN BGN SCALP/HND 1.1-2.0 EACH 11422 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940658 CLINIC LESN BGN SCALP/HND 2.1-3.0 EACH 11423 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940666 CLINIC LESN BGN SCALP/HND 3.1-4.0 EACH 11424 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940633 CLINIC LESN BGN SCLP/HND .6-1.0CM EACH 11421 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940898 CLINIC LESN MAL FACE/EAR 1.1-2.0 EACH 11642 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940773 CLINIC LESN MAL TRUNK/ARM 1.1-2.0 EACH 11602 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51945954 CLINIC "LIGATION/BX, TEMPORAL ART " EACH 37609 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946911 CLINIC LYSIS OF LABIAL ADHESIONS EACH 56441 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 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Charges 65% of Billed Charges 65% of Billed Charges 51919751 CLINIC NUTRITION EDUCATION-GROUP 2-4 EACH 98961 $72.00 942 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919769 CLINIC NUTRITION EDUCATION-GROUP 5-8 EACH 98962 $48.00 942 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919744 CLINIC NUTRITION EDUCATION-INDIVIDUAL EACH 98960 $96.00 942 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51921351 CLINIC OBTAIN SCREEN PAP SMEAR EACH Q0091 $74.00 923 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51918647 CLINIC ON DEMAND VIDEO VISIT EACH $59.00 510 $41.30 $29.50 $47.20 65% 80% 50% 50% 65% Non Payable Non Payable 51952570 CLINIC OPENTXTIBIALFRACTURE EACH 27535 "$6,397.00 " 510 "$4,477.90 " "$3,198.50 " "$5,117.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51908846 CLINIC ORAL MEDICATION ADMIN EACH H0033 $150.00 761 $105.00 $75.00 $120.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51944734 CLINIC OSTEOCHONDRAL TALUS AUTOGR EACH 28446 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952182 CLINIC OSTEOPATHMAN1-2REGIONS EACH 98925 $65.00 530 $45.50 $32.50 $52.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51952190 CLINIC OSTEOPATHMAN3-4REGIONS EACH 98926 $65.00 530 $45.50 $32.50 $52.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51952208 CLINIC OSTEOPATHMAN5-6REGIONS EACH 98927 $65.00 530 $45.50 $32.50 $52.00 65% of Billed Charges 80% of Billed Charges 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15574 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941763 CLINIC PEDICLE E/N/E/L/NTRORAL EACH 15576 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946812 CLINIC PENILE INJECTION EACH 54235 $612.00 510 $428.40 $306.00 $489.60 65% 80% 50% 50% 65% Non Payable Non Payable 51951986 CLINIC "PENISPLASTICSURG,ANGUL " EACH 54360 "$8,620.00 " 510 "$6,034.00 " "$4,310.00 " "$6,896.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947430 CLINIC PERC EPID LYSIS INJ MULTI EACH 62263 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948156 CLINIC PERQ IMP ELECT SACRL NERVE EACH 64561 "$16,910.00 " 510 "$11,837.00 " "$8,455.00 " "$13,528.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947679 CLINIC PERQ REM SPINE ELTRD ARRAY EACH 63661 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947687 CLINIC PERQ REV SPINE ELTRD ARRAY EACH 63663 "$16,910.00 " 510 "$11,837.00 " "$8,455.00 " "$13,528.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51925287 CLINIC PFIZ COV2 BIV BSTR 12+ SDV ADM EACH 0124A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51925261 CLINIC PFIZ COV2 BIV BSTR 12Y+ ADM EACH 0124A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51925246 CLINIC PFIZ COV2 BIVAL BSTR 5-11Y ADM EACH 0154A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51925329 CLINIC PFIZ COV2 BIVAL BSTR 6M-4Y ADM EACH $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51921666 CLINIC PFIZER COV-19 6-59 MO DOSE 1 EACH 0081A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51921682 CLINIC PFIZER COV-19 6-59 MO DOSE 2 EACH 0082A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51924983 CLINIC PFIZER COV19 VAC ADM PED DS 1 EACH 0071A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51925014 CLINIC PFIZER COV19 VAC ADM PED DS 2 EACH 0072A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51925113 CLINIC PFIZER COV19 VAC ADM PED DS 3 EACH 0073A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51925147 CLINIC PFIZER COV19 VAC ADM T/S DS 1 EACH 0051A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51925162 CLINIC PFIZER COV19 VAC ADM T/S DS 2 EACH 0052A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51925188 CLINIC PFIZER COV19 VAC ADM T/S DS 3 EACH 0053A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51918720 CLINIC PFIZER COV19 VAC ADMIN DOSE 1 EACH 0001A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51918738 CLINIC PFIZER COV19 VAC ADMIN DOSE 2 EACH 0002A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51919900 CLINIC PFIZER COV19 VAC ADMIN DOSE 3 EACH 0004A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51921393 CLINIC PFIZER COV19 VAC T/S BOOSTER 1 EACH 0054A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51921633 CLINIC PFIZER COV19 VAC T/S BOOSTER 2 EACH 0054A $108.00 771 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51951861 CLINIC PF-KIDNEYENDOSCOPY&TX EACH 50561 "$12,794.00 " 510 "$8,955.80 " "$6,397.00 " "$10,235.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949899 CLINIC PHOTOCHEMOTHRPY UVB EACH 96910 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51942381 CLINIC PLACE BRST LOC DEV ADD EACH 19284 $372.00 510 $260.40 $186.00 $297.60 65% 80% 50% 50% 65% Non Payable Non Payable 51942423 CLINIC PLACE BRST LOC DEVI + MRI EACH 19288 $478.00 510 $334.60 $239.00 $382.40 65% 80% 50% 50% 65% Non Payable Non Payable 51942407 CLINIC PLACE BRST LOC DEVI + US EACH 19286 $320.00 510 $224.00 $160.00 $256.00 65% 80% 50% 50% 65% Non Payable Non Payable 51942415 CLINIC PLACE BRST LOC DEVI 1 MRI EACH 19287 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942373 CLINIC PLACE BRST LOC DEVI 1ST EACH 19283 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942399 CLINIC PLACE BRST LOC DEVI 1ST US EACH 19285 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952075 CLINIC PLACEEXTVENTRICDRAIN EACH 61107 "$6,440.00 " 510 "$4,508.00 " "$3,220.00 " "$5,152.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51916559 CLINIC POC US PELVIC NON-OB TRANSVAG EACH $287.00 402 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable Non Payable Non Payable 51918373 CLINIC PREVENTIVE MED ESTAB < 1 YR EACH 99391 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918431 CLINIC PREVENTIVE MED ESTAB > 65 Y EACH 99397 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918407 CLINIC PREVENTIVE MED ESTAB 12-17 EACH 99394 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918381 CLINIC PREVENTIVE MED ESTAB 1-4 YR EACH 99392 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918415 CLINIC PREVENTIVE MED ESTAB 18-39 EACH 99395 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918423 CLINIC PREVENTIVE MED ESTAB 40-64 EACH 99396 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918399 CLINIC PREVENTIVE MED ESTAB 5-11 Y EACH 99393 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918308 CLINIC PREVENTIVE MED NEW < 1 YR EACH 99381 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918365 CLINIC PREVENTIVE MED NEW > 65 YRS EACH 99387 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918332 CLINIC PREVENTIVE MED NEW 12-17 YR EACH 99384 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918316 CLINIC PREVENTIVE MED NEW 1-4 YRS EACH 99382 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918340 CLINIC PREVENTIVE MED NEW 18-39 YR EACH 99385 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918357 CLINIC PREVENTIVE MED NEW 40-64 YR EACH 99386 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918324 CLINIC PREVENTIVE MED NEW 5-11 YRS EACH 99383 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51952968 CLINIC PRIN CARE MGMT STAFF 1ST 30 EACH 99426 $221.00 510 $154.70 $110.50 $176.80 65% 80% 50% 50% 65% Non Payable Non Payable 51952976 CLINIC PRIN CARE MGMT STAFF ADDL 30M EACH 99427 $99.00 510 $69.30 $49.50 $79.20 65% 80% 50% 50% 65% Non Payable Non Payable 51952653 CLINIC PROLNG OP E/M EACH 15 MIN EACH 99417 $93.00 510 $65.10 $46.50 $74.40 65% 80% 50% 50% 65% Non Payable Non Payable 51946879 CLINIC PROSTATE SATURATION SAMP EACH 55706 "$8,620.00 " 510 "$6,034.00 " "$4,310.00 " "$6,896.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952695 CLINIC PT-FOCUSED HLTH RISK ASSMT EACH 96160 $71.00 510 $49.70 $35.50 $56.80 65% 80% 50% 50% 65% Non Payable Non Payable 51949808 CLINIC PUMP MAINT SPINAL/BRAIN EACH 95990 $838.00 510 $586.60 $419.00 $670.40 65% 80% 50% 50% 65% Non Payable Non Payable 51940377 CLINIC PUNCH SKIN BIOPSY 1ST EACH 11104 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51940385 CLINIC PUNCH SKIN BIOPSY ADDL EACH 11105 $111.00 510 $77.70 $55.50 $88.80 65% 80% 50% 50% 65% Non Payable Non Payable 51952000 CLINIC PUNCTASPHYDROCELE/TUNICA EACH 55000 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944643 CLINIC RECONSTRUCT CLEFT FOOT EACH 28360 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941029 CLINIC RECONSTRUCT NAIL BED W/GR EACH 11762 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942712 CLINIC RECONSTRUCTION OF JAW EACH 21248 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951978 CLINIC RECONSTRUCTIONOFURETHRA EACH 54322 "$8,620.00 " 510 "$6,034.00 " "$4,310.00 " "$6,896.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51919587 CLINIC REFILL/MAINT PUMP/RESVR SYST EACH 96522 $530.00 260 $371.00 $265.00 $424.00 65% 80% 50% 50% 65% 65% 65% 51944221 CLINIC RELEASE EXTENS TENDON-MULT EACH 28226 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944213 CLINIC RELEASE EXTENSOR TENDON 1 EACH 28225 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944205 CLINIC RELEASE FLEXOR TEND-MULTI EACH 28222 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944338 CLINIC RELEASE FOOT CONTRACTURE EACH 28270 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943454 CLINIC RELEASE LOWER LEG TEND EA EACH 27680 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943462 CLINIC RELEASE LOWER LEG TENDONS EACH 27681 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944296 CLINIC RELEASE MIDFOOT JT ONLY EACH 28260 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944320 CLINIC RELEASE MIDTARSAL (HEYMAN) EACH 28264 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944270 CLINIC RELEASE OF BIG TOE EACH 28240 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944346 CLINIC RELEASE OF TOE JOINT EACH EACH 28272 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943140 CLINIC RELEASE PALM CONTRACTURE EACH 26123 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943678 CLINIC RELEASE TARSAL TUNNEL EACH 28035 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948693 CLINIC REM BLOOD CLOT ANT SEG EYE EACH 65930 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941110 CLINIC REM CONTRACEPTIVE CAPSULE EACH 11976 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948610 CLINIC REM CORNEAL EPITHEL/CHELAT EACH 65436 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947281 CLINIC REM DVC INTRAUTERINE EACH 58301 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 51942696 CLINIC REM EXOSTOSIS MANDIBLE EACH 21031 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948487 CLINIC REM FB CONJUCT EMBED EACH 65210 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51948495 CLINIC REM FB CORNEAL W/O SLIT EACH 65220 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51948503 CLINIC REM FB CORNEAL W/SLIT LAMP EACH 65222 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942910 CLINIC REM FB DEEP SHOULDER EACH 23333 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946051 CLINIC REM FB EMBED MOUTH SIMPLE EACH 40804 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949378 CLINIC REM FB EYELID EMBEDDED EACH 67938 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51944130 CLINIC REM FB FOOT SUBQ EACH 28190 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945657 CLINIC REM FB NASAL EACH 30300 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51946226 CLINIC REM FB PHARYNX EACH 42809 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51944148 CLINIC REM FOREIGN BODY FOOT DEEP EACH 28192 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51950038 CLINIC REM RETINAL IMAGING-SCREEN EACH 92227 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51945533 CLINIC REM/BIV FULL ARM/LEG CAST EACH 29705 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51943884 CLINIC REM/GRAFT FT LES W/GRAFT EACH 28102 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941151 CLINIC REM/INS DRUG IMPLANT EACH 11983 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51950046 CLINIC REMOTE RETINAL IMAGING MGMT EACH 92228 $100.00 510 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% Non Payable Non Payable 51943785 CLINIC "REMOVAL FOOT FASCIA, PART " EACH 28060 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945632 CLINIC REMOVAL INTRANASAL LESION EACH 30117 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944056 CLINIC REMOVAL OF ANKLE BONE EACH 28130 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943876 CLINIC REMOVAL OF ANKLE/HEEL LES EACH 28100 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943165 CLINIC REMOVAL OF FINGER LESION EACH 26210 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943991 CLINIC REMOVAL OF HEEL BONE EACH 28118 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944007 CLINIC REMOVAL OF HEEL SPUR EACH 28119 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944064 CLINIC REMOVAL OF METATARSAL EACH 28140 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944577 CLINIC REMOVAL OF SESAMOID BONE EACH 28315 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942613 CLINIC REMOVAL OF SUPPORT IMPLANT EACH 20680 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944072 CLINIC "REMOVAL OF TOE, EACH TOE " EACH 28150 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951788 CLINIC REMOVALOFSALIVARYSTONE EACH 42335 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951796 CLINIC REMOVALOFTONSILS<12YRS EACH 42825 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951804 CLINIC REMOVALOFTONSILS>12YRS EACH 42826 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942993 CLINIC REMOVE ARM FOREIGN BODY EACH 24200 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942621 CLINIC REMOVE BONE FIXATION DEV EACH 20694 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942902 CLINIC REMOVE BONE LESION EACH 23140 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941144 CLINIC REMOVE DRUG IMPLANT DEVICE EACH 11982 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51949683 CLINIC REMOVE EAR CANAL LESION(S) EACH 69145 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942985 CLINIC REMOVE ELBOW LESION EACH 24120 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949675 CLINIC REMOVE EXT EAR PARTIAL EACH 69110 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943850 CLINIC REMOVE FOOT CYST/GANGLION EACH 28090 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943793 CLINIC REMOVE FOOT FASCIA-RADICAL EACH 28062 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943892 CLINIC REMOVE FOOT LESION TAR/MET EACH 28104 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943827 CLINIC REMOVE FOOT LESION-MORTON EACH 28080 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944155 CLINIC "REMOVE FT FOREIGN BODY, SC " EACH 28193 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943967 CLINIC REMOVE FTH METATARSAL HEAD EACH 28113 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948792 CLINIC REMOVE INNER EYE LESION EACH 66770 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943900 CLINIC REMOVE LES TAR/MET W/GRAFT EACH 28106 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948412 CLINIC REMOVE LIMB NERVE LESION EACH 64782 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943975 CLINIC REMOVE METATARSL (CLAYTON) EACH 28114 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943173 CLINIC REMOVE PARTIAL FINGER BONE EACH 26235 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941045 CLINIC REMOVE PILONIDAL CYST SMP EACH 11770 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948420 CLINIC REMOVE SKIN NERVE LESION EACH 64788 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940435 CLINIC REMOVE SKIN TAG EA ADDL 10 EACH 11201 $150.00 510 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940427 CLINIC REMOVE SKIN TAG UP TO 15 EACH 11200 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51952687 CLINIC REMOVE SUTR & STAPL WO ANES EACH 15854 $25.00 510 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% Non Payable Non Payable 51952679 CLINIC REMOVE SUTR OR STAPL WO ANES EACH 15853 $25.00 510 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940740 CLINIC REMOVE SWEAT GLAND LES EACH 11450 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943157 CLINIC REMOVE TENDON SHEATH LES EACH 26160 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943926 CLINIC REMOVE TOE BONE CYSTS EACH 28108 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943868 CLINIC REMOVE TOE LESIONS EACH 28092 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947034 CLINIC REMOVE VAGINA LESION EACH 57135 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943033 CLINIC REMOVE WRIST TENDON LES EACH 25110 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943041 CLINIC REMOVE WRIST TENDON LESION EACH 25111 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943918 CLINIC REMOVE/GRAFT LES W/ALLOG EACH 28107 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951127 CLINIC REMSUTUREANESOTHERMD EACH 15851 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951226 CLINIC REMTONG/HALOOTHERMDAPPL EACH 20665 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51944957 CLINIC REP OPEN TALOTARSAL DISLOC EACH 28585 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944981 CLINIC REP OPEN TARSOMET DISLOCAT EACH 28615 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943421 CLINIC REPAIR ACHILLES TENDON EACH 27650 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943447 CLINIC REPAIR ACHILLES TENDON 2ND EACH 27654 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944569 CLINIC REPAIR DEFORMITY OF TOE EACH 28313 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948925 CLINIC REPAIR DETACHED RETINA EACH 67107 "$10,053.00 " 510 "$7,037.10 " "$5,026.50 " "$8,042.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944627 CLINIC REPAIR EXTRA TOE(S) EACH 28344 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943207 CLINIC REPAIR FINGER TENDON EACH 26418 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944395 CLINIC REPAIR HALLUX RIGIDUS EACH 28289 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944379 CLINIC REPAIR HAMMERTOE EACH 28286 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943199 CLINIC REPAIR HAND TENDON EACH 26410 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948743 CLINIC REPAIR IRIS & CILIARY BODY EACH 66680 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949329 CLINIC REPAIR OF ENTROPION SUTURE EACH 67921 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944585 CLINIC REPAIR OF FOOT BONES EACH 28320 "$32,541.00 " 510 "$22,778.70 " "$16,270.50 " "$26,032.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944189 CLINIC REPAIR OF FOOT TENDON EACH 28208 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944361 CLINIC REPAIR OF HAMMERTOE EACH 28285 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944593 CLINIC REPAIR OF METATARSALS EACH 28322 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941011 CLINIC REPAIR OF NAIL BED EACH 11760 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945061 CLINIC REPAIR OF OPEN TOE DISLOC EACH 28675 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946200 CLINIC REPAIR OF SALIVARY DUCT EACH 42500 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944916 CLINIC REPAIR OPEN TARSAL DISLOC EACH 28555 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945020 CLINIC REPAIR OPEN TOE DISLOC EACH 28645 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947083 CLINIC REPAIR RECTUM & VAGINA EACH 57250 "$12,298.00 " 510 "$8,608.60 " "$6,149.00 " "$9,838.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944635 CLINIC REPAIR WEBBED TOE(S) EACH 28345 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943439 CLINIC REPAIR/GRAFT ACHILLES TEN EACH 27652 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944197 CLINIC REPAIR/GRAFT FOOT TENDON EACH 28210 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944163 CLINIC REPAIR/GRAFT FOOT TENDON-1 EACH 28200 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944171 CLINIC REPAIR/GRAFT FOOT TENDON-2 EACH 28202 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951416 CLINIC REPAIRPERONEALTENDONS EACH 27676 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948859 CLINIC REPLACE EYE FLUID EACH 67025 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943058 CLINIC RER WRIST TENDON LESION EACH 25112 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944619 CLINIC RESECT ENLARGED TOE EACH 28341 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944601 CLINIC RESECT ENLARGED TOE TISSUE EACH 28340 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943728 CLINIC RESECT FOOT/TOE TUMOR < 3 EACH 28046 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943736 CLINIC RESECT FOOT/TOE TUMOR 3> EACH 28047 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945640 CLINIC RESECT INFERIOR TURBINATE EACH 30140 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943405 CLINIC RESECT LEG/ANKLE TUM 5> EACH 27616 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944114 CLINIC RESECT METATARSAL TUMOR EACH 28173 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944122 CLINIC RESECT PHALANX TOE TUMOR EACH 28175 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944106 CLINIC RESECT TARSAL TUMOR EACH 28171 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947703 CLINIC REV/REM NEURORECEIVER EACH 63688 "$8,413.00 " 510 "$5,889.10 " "$4,206.50 " "$6,730.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945129 CLINIC REVISE FT BONES (MILLER) EACH 28737 "$32,541.00 " 510 "$22,778.70 " "$16,270.50 " "$26,032.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943470 CLINIC REVISE LOWER LEG TENDON EACH 27685 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944312 CLINIC REVISE MIDFT EXT-CLUBFOOT EACH 28262 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944262 CLINIC REVISE POST TIBIAL TENDON EACH 28238 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943488 CLINIC REVISION LOWER LEG TENDONS EACH 27686 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944544 CLINIC REVISION OF BIG TOE EACH 28310 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947406 CLINIC REVISION OF CERVIX EACH 59320 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943983 CLINIC REVISION OF FOOT - TASRSAL EACH 28116 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944288 CLINIC REVISION OF FOOT FASCIA EACH 28250 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941888 CLINIC REVISION OF LOWER EYELID EACH 15821 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944304 CLINIC REVISION OF MIDFOOT TENDON EACH 28261 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944551 CLINIC REVISION OF TOE (NOT BIG) EACH 28312 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941904 CLINIC REVISION OF UPPER EYELID EACH 15823 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51921344 CLINIC RF ABLTJ NRV NRVTG SI JT EACH 64625 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952356 CLINIC RISKREDUCTGROUP30MIN EACH 99411 $70.00 510 $49.00 $35.00 $56.00 65% 80% 50% 50% 65% Non Payable Non Payable 51952364 CLINIC RISKREDUCTGROUP60MIN EACH 99412 $138.00 510 $96.60 $69.00 $110.40 65% 80% 50% 50% 65% Non Payable Non Payable 51952299 CLINIC RISKREDUCTINDIV15MIN EACH 99401 $57.00 510 $39.90 $28.50 $45.60 65% 80% 50% 50% 65% Non Payable Non Payable 51952307 CLINIC RISKREDUCTINDIV30MIN EACH 99402 $96.00 510 $67.20 $48.00 $76.80 65% 80% 50% 50% 65% Non Payable Non Payable 51952315 CLINIC RISKREDUCTINDIV45MIN EACH 99403 $144.00 510 $100.80 $72.00 $115.20 65% 80% 50% 50% 65% Non Payable Non Payable 51952323 CLINIC RISKREDUCTINDIV60MIN EACH 99404 $194.00 510 $135.80 $97.00 $155.20 65% 80% 50% 50% 65% Non Payable Non Payable 51920536 CLINIC RME-DAILY RECORDINGS > 16 DAYS EACH 99454 $94.00 510 $65.80 $47.00 $75.20 65% 80% 50% 50% 65% Non Payable Non Payable 51952562 CLINIC RME-DAILYRECORDINGS>16DAY EACH 99454 $0.00 510 $0.00 $0.00 $0.00 65% 80% 50% 50% 65% Non Payable Non Payable 51920528 CLINIC RME-INITIAL SET-UP & EDUCATION EACH 99453 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51952554 CLINIC RME-INITIALSET-UP&EDUC EACH 99453 $0.00 510 $0.00 $0.00 $0.00 65% 80% 50% 50% 65% Non Payable Non Payable 51948537 CLINIC RPR LAC CONJUNCT EACH 65272 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51948552 CLINIC RPR LAC CORNEA W/GLUE EACH 65286 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941524 CLINIC RPR LAC CPLX EYE 1.1-2.5CM EACH 13151 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941532 CLINIC RPR LAC CPLX EYE 2.6-7.5CM EACH 13152 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941490 CLINIC RPR LAC CPLX FHD 1.1-2.5CM EACH 13131 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941458 CLINIC RPR LAC CPLX TK EA AD 5 CM EACH 13102 $805.00 510 $563.50 $402.50 $644.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941441 CLINIC RPR LAC CPLX TRK 2.6-7.5CM EACH 13101 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941383 CLINIC RPR LAC INT FACE 5.1-7.5CM EACH 12053 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941367 CLINIC RPR LAC INT FCE/EAR 2.5CM+ EACH 12051 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941284 CLINIC RPR LAC SMP FACE >30.0 CM EACH 12018 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941268 CLINIC RPR LAC SMP FACE 12.1-20.0 EACH 12016 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941276 CLINIC RPR LAC SMP FACE 20.1-30.0 EACH 12017 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941201 CLINIC RPR S/N/A/GEN/TRK20.1-30.0 EACH 12006 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941219 CLINIC RPR S/N/AX/GEN/TRNK >30.0 EACH 12007 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951739 CLINIC SCLEROSOLNVEINLIMB/TR EACH 36468 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51948602 CLINIC SCRAPING CORNEA DX EACH 65430 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51904134 CLINIC SCRN VISUAL ACUITY BI EACH 99173 $20.00 920 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51952612 CLINIC SELF-MEAS BP PT EDUCAJ/TRAIN EACH 99473 $74.00 942 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51940476 CLINIC SHAVE SKIN LESION >2.0 CM EACH 11303 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51940534 CLINIC SHV LESN FACE/EAR .6-1.0CM EACH 11311 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940559 CLINIC SHV LESN FACE/EAR >2.0CM EACH 11313 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51940542 CLINIC SHV LESN FACE/EAR 1.1-2CM EACH 11312 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51940526 CLINIC SHV LESN FACE/EAR TO 0.5CM EACH 11310 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940518 CLINIC SHV LESN SKN SCALP >2.0CM EACH 11308 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51940500 CLINIC SHV LESN SKN SCALP 1.1-2CM EACH 11307 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940484 CLINIC SHV LESN SKN SCALP TO .5CM EACH 11305 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940492 CLINIC SHV LESN SKN SCALP.6-1.0CM EACH 11306 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940450 CLINIC SHV LESN TRK/ARM 0.6-1.0CM EACH 11301 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940468 CLINIC SHV LESN TRK/ARM 1.1-2.0CM EACH 11302 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940443 CLINIC SHV LESN TRUNK/ARM TO .5CM EACH 11300 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 75102525 CLINIC SIGMOIDOSCOPY AND BIOPSY EACH 45331 "$2,260.00 " 750 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% 80% Covered Charges NTE $1501/case $660 $600 $72.04 $824 $824 51951895 CLINIC SIMPLECYSTOMETROGRAM EACH 51725 $612.00 510 $428.40 $306.00 $489.60 65% 80% 50% 50% 65% Non Payable Non Payable 51941698 CLINIC SKIN FULL GRAFT EEN & LIPS EACH 15260 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941672 CLINIC SKIN FULL GRFT FACE/GENIT EACH 15240 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941664 CLINIC SKIN SPLT GRFT TRK/ARM/LEG EACH 15100 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941722 CLINIC SKIN SUB GRAFT F/N/HF/G + EACH 15276 $880.00 510 $616.00 $440.00 $704.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941714 CLINIC SKIN SUB GRAFT FACE/NK/HF EACH 15275 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941573 CLINIC SKIN TISSUE REARRANGE TRNK EACH 14001 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942282 CLINIC SKIN/MUC MEM/SUBQ TISS NOS EACH 17999 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951069 CLINIC SKINGRAFTT/A/LGCHADDON EACH 15274 "$1,728.00 " 510 "$1,209.60 " $864.00 "$1,382.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951051 CLINIC SKINGRAFTT/ARM/LGCHILD EACH 15273 "$8,871.00 " 510 "$6,209.70 " "$4,435.50 " "$7,096.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951184 CLINIC SKINPEELTHERAPY EACH 17360 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951044 CLINIC SKINSUBGRAFTT/A/LADD-ON EACH 15272 $968.00 510 $677.60 $484.00 $774.40 65% 80% 50% 50% 65% Non Payable Non Payable 51951036 CLINIC SKINSUBGRAFTTRNK/ARM/LEG EACH 15271 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941730 CLINIC SKN SUB GRFT F/N/HF/G CH EACH 15277 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941748 CLINIC SKN SUB GRFT F/N/HF/G CH + EACH 15278 $880.00 510 $616.00 $440.00 $704.00 65% 80% 50% 50% 65% Non Payable Non Payable 51946242 CLINIC SMALL BOWEL ENDOSCOPY EACH 44360 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952349 CLINIC SMOKCESSINTEN>10MIN EACH 99407 $71.00 942 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51952331 CLINIC SMOKCESSINTER>3MIN EACH 99406 $71.00 942 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919785 CLINIC SMOKING CESSATION-GROUP 2-4 EACH 98961 $72.00 942 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919793 CLINIC SMOKING CESSATION-GROUP 5-8 EACH 98962 $48.00 942 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919777 CLINIC SMOKING CESSATION-INDIVIDUAL EACH 98960 $96.00 942 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51951937 CLINIC STIMULUSEVOKEDRESPONSE EACH 51792 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51945491 CLINIC STRAP UNNA BOOT EACH 29580 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945327 CLINIC STRAPPING HAND/FINGER EACH 29280 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51951622 CLINIC STRAPPINGELBOWORWRIST EACH 29260 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51951630 CLINIC STRAPPINGOFHIP EACH 29520 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51951648 CLINIC STRAPPINGOFKNEE EACH 29530 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51951614 CLINIC STRAPPINGTHORAX EACH 29200 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51919819 CLINIC STRESS MANAGEMENT-GROUP 2-4 EACH 98961 $72.00 942 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919827 CLINIC STRESS MANAGEMENT-GROUP 5-8 EACH 98962 $48.00 942 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51919801 CLINIC STRESS MANAGEMENT-INDIVIDUAL EACH 98960 $96.00 942 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51946689 CLINIC STUDY VP INTRA-ABDOMINAL EACH 51797 $340.00 510 $238.00 $170.00 $272.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951853 CLINIC STUDYMANOMETRICRENAL EACH 50396 "$1,689.00 " 510 "$1,182.30 " $844.50 "$1,351.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941938 CLINIC SUCT LIPECTOMY HEAD&NECK EACH 15876 "$8,871.00 " 510 "$6,209.70 " "$4,435.50 " "$7,096.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946903 CLINIC SURGERY FOR VULVA LESION EACH 56440 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51939718 CLINIC "SURGICAL, INDUCED, D & C " EACH 59840 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943801 CLINIC SYNOVECTMY INTER/TAR JT EA EACH 28070 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943819 CLINIC SYNOVECTOMY METATAR JT EA EACH 28072 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940351 CLINIC TANGENTIAL SKIN BIOPSY 1ST EACH 11102 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51940369 CLINIC TANGENTIAL SKIN BIOPSY ADD EACH 11103 $28.00 510 $19.60 $14.00 $22.40 65% 80% 50% 50% 65% Non Payable Non Payable 51948024 CLINIC TAP BLOCK BI BY INFUSION EACH 64489 $150.00 510 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% Non Payable Non Payable 51948016 CLINIC TAP BLOCK BILATERAL INJ EACH 64488 $150.00 510 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% Non Payable Non Payable 51948008 CLINIC TAP BLOCK UNI BY INFUSION EACH 64487 $150.00 510 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% Non Payable Non Payable 51947992 CLINIC TAP BLOCK UNIL BY INJ EACH 64486 $150.00 510 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% Non Payable Non Payable 51950996 CLINIC TATTOOMICROPIGMENT<6.0CM EACH 11920 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951002 CLINIC TATTOOMICROPIGMENT6.1-20. EACH 11921 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951010 CLINIC TATTOOMICROPIGMENTADD20 EACH 11922 $625.00 510 $437.50 $312.50 $500.00 65% 80% 50% 50% 65% Non Payable Non Payable 51918662 CLINIC TELEPHONE ASSMT NONMD 11-20 M EACH 98967 $70.00 510 $49.00 $35.00 $56.00 65% 80% 50% 50% 65% Non Payable Non Payable 51918670 CLINIC TELEPHONE ASSMT NONMD 21-30 M EACH 98968 $107.00 510 $74.90 $53.50 $85.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918654 CLINIC TELEPHONE ASSMT NONMD 5-10 MIN EACH 98966 $35.00 510 $24.50 $17.50 $28.00 65% 80% 50% 50% 65% Non Payable Non Payable 51918811 CLINIC TELEPHONE VISIT 11-20 M EACH 99442 $327.00 519 $228.90 $163.50 $261.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51918829 CLINIC TELEPHONE VISIT 21-30 M EACH 99443 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918803 CLINIC TELEPHONE VISIT 5-10 MIN EACH 99441 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51945723 CLINIC THER FX NASAL INF TURB EACH 30930 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941623 CLINIC TIS TRNFR E/N/E/L10.1-30 EACH 14061 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941565 CLINIC TIS TRNFR TRUNK 10 SQ CM/< EACH 14000 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941607 CLINIC TIS XFER F/C/C/M/N/A/G/H/F EACH 14041 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941581 CLINIC TIS XFER S/A/L 10 SQ CM< EACH 14020 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941599 CLINIC TIS XFR F/C/C/M/N/A/G/H/F EACH 14040 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51925550 CLINIC TONGUE & MOUTH SURGERY EACH 41599 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% Non Payable Non Payable 51948677 CLINIC TRABECULOPLASTY LASER EACH 65855 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51952380 CLINIC TRANSCAREMGMT7DAYDISCH EACH 99496 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51952372 CLINIC TRANSCAREMGT14DAYDISCH EACH 99495 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51943553 CLINIC TREAT ANKLE DISLOCATION EACH 27848 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943603 CLINIC TREAT FOOT BONE LESION EACH 28005 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943595 CLINIC TREAT FOOT INFECTION EACH 28003 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944684 CLINIC TREAT HEEL FRACTURE EACH 28415 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51942753 CLINIC TREAT LOWER JAW FRACTURE EACH 21453 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944692 CLINIC TREAT/GRAFT HEEL FRACTURE EACH 28420 "$32,541.00 " 510 "$22,778.70 " "$16,270.50 " "$26,032.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951283 CLINIC TREATFXRADINTRA-ARTICUL EACH 25608 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51905685 CLINIC TREATMENT INCOMPLETE ABORTION EACH 59812 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51905693 CLINIC TREATMENT OF MISSED ABORTION EACH 59820 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51940930 CLINIC TRIM NAILS NONDYSTROPHIC EACH 11719 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51940328 CLINIC TRIM SKIN LESION EACH 11055 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51944700 CLINIC TX ANKLE FRACT CLOSED W EACH 28435 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944718 CLINIC TX ANKLE FRACT PERC W/MAP EACH 28436 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941953 CLINIC TX BURN 1ST DEGREE INITIAL EACH 16000 $495.00 510 $346.50 $247.50 $396.00 65% 80% 50% 50% 65% Non Payable Non Payable 51951291 CLINIC TX CARP SCAPH FX; W/O MANIP EACH 25622 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951309 CLINIC TX CARPAL BONE;W/O EA BONE EACH 25630 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944932 CLINIC TX CL FT DISLOCAT W/ANES EACH 28575 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945046 CLINIC TX CL INTPHLNGL DISLOC W EACH 28665 $665.00 510 $465.50 $332.50 $532.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945038 CLINIC TX CL INTPHLNGL DISLOC WO EACH 28660 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944866 CLINIC TX CL SESAMOID BONE FRACT EACH 28530 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51942936 CLINIC TX CLAVICLE DISLOC EACH 23550 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944999 CLINIC TX CLOSD METAPH DISLOC WO EACH 28630 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944965 CLINIC TX CLOSD TARSMET DISLOC W/ EACH 28605 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944809 CLINIC TX CLOSED BIG TOE FRACTURE EACH 28495 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944890 CLINIC TX CLOSED FOOT DISLOCAT W/ EACH 28545 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945004 CLINIC TX CLOSED METAPH DISLOC W/ EACH 28635 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944775 CLINIC TX CLOSED METATARSAL FRACT EACH 28475 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944924 CLINIC TX CLOSED TAL DISLOCAT WO EACH 28570 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944882 CLINIC TX CLOSED TARSL DISLOC WO EACH 28540 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944841 CLINIC TX CLOSED TOE FRACT W/MAN EACH 28515 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944833 CLINIC TX CLOSED TOE FRACT WO MAN EACH 28510 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943546 CLINIC TX DISLOC ANKLE EACH 27840 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51950426 CLINIC TX DISLOC FINGER EACH 26770 $584.00 263 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% 65% 65% 51943249 CLINIC TX DISLOC HAND W/MAN EA JT EACH 26670 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943348 CLINIC TX DISLOC KNEECAP W/O ANES EACH 27560 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943587 CLINIC TX FOOT INFECTION EACH 28002 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943520 CLINIC TX FX ANKLE BIMALLEOLR W/O EACH 27808 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943512 CLINIC TX FX ANKLE DISTAL FIB W/O EACH 27786 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943504 CLINIC TX FX ANKLE FIBULA W/O MAN EACH 27780 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943496 CLINIC TX FX ANKLE MEDIAL W/O MAN EACH 27760 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951432 CLINIC TX FX ANKLE POST; W/O MANIP EACH 27767 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943538 CLINIC TX FX ANKLE TRIMALL W/O EACH 27816 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951317 CLINIC TX FX ARTICULAR; W/O MANIP EACH 26740 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951507 CLINIC TX FX BIG TOE; W/O MANIP EACH 28490 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51950384 CLINIC TX FX FINGER EACH 26720 $584.00 263 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% 65% 65% 51950392 CLINIC TX FX FINGER EACH 26725 $584.00 263 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% 65% 65% 51943330 CLINIC TX FX KNEE EACH 27538 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951341 CLINIC TX FX KNEE; W/O MANIP EACH 27530 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951333 CLINIC TX FX KNEECAP; W/O MANIP EACH 27520 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951465 CLINIC TX FX LOWER LEG; W/O MANIP EACH 27824 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943223 CLINIC TX FX METACARP 1 W/MANIP EACH 26600 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951499 CLINIC TX FX METATARSAL; W/O MANIP EACH 28470 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951481 CLINIC TX FX MIDFOOT; W/O MANIP EACH 28450 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943066 CLINIC TX FX RAD AND ULNA EACH 25520 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51943082 CLINIC TX FX RAD/ULNA W/O MANIP EACH 25560 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951275 CLINIC TX FX RADIUS;W/O MANIP EACH 25500 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51950517 CLINIC TX FX TIBIA EACH 27752 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951424 CLINIC TX FX TIBIA; W/O MANIP EACH 27750 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51943074 CLINIC TX FX ULNA W/O MANIP EACH 25530 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944650 CLINIC TX HEEL FRAC CLOSED WO MAN EACH 28400 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944668 CLINIC TX HEEL FRACT CLOSED W/MAN EACH 28405 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51944676 CLINIC TX HEEL FRACT PERCUT W/MAN EACH 28406 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944742 CLINIC TX MIDFOOT FRACT W/MAP EACH 28455 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51907970 CLINIC "TX MISSED ABORTION,SECOND TRIM" EACH 59821 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944726 CLINIC TX OPEN ANKLE FRACTURE EACH 28445 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944825 CLINIC TX OPEN BIG TOE FRACTURE EACH 28505 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944791 CLINIC TX OPEN METATARSAL FRACT EACH 28485 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944767 CLINIC TX OPEN MIDFOOT FRACT EA EACH 28465 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944874 CLINIC TX OPEN SESAMOID BONE FRAC EACH 28531 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944858 CLINIC TX OPEN TOE FRACTURE EACH 28525 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945053 CLINIC TX PERC INTRPHLNGL DISLOC EACH 28666 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51945012 CLINIC TX PERC METATPHALN DISLOC EACH 28636 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944759 CLINIC TX PERC MIDFT FRACT W/O EACH 28456 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944940 CLINIC TX PERC TALOTARSAL DISLOC EACH 28576 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944908 CLINIC TX PERC TARSAL DISLOCATION EACH 28546 "$3,974.00 " 510 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944973 CLINIC TX PERC TARSMETAT DISLOC EACH 28606 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944817 CLINIC TX PERCUT BIG TOE FRACTURE EACH 28496 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51944783 CLINIC TX PERCUT METATARSAL FRACT EACH 28476 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951515 CLINIC TXCLOSDTARSOMETJTW/OAN EACH 28600 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951473 CLINIC TXCLOSEDANKLEFRACTURE EACH 28430 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951358 CLINIC TXCLOSEDNOSEFXW/OSTABL EACH 27607 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951440 CLINIC TXDISTALFIBULARFX EACH 27792 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951325 CLINIC TXFXDISTAL EACH 26750 $584.00 510 $408.80 $292.00 $467.20 65% 80% 50% 50% 65% Non Payable Non Payable 51951457 CLINIC TXOPENANKLEFRACTURE EACH 27814 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949949 CLINIC ULTRAVIOLET THERAPY EACH 97028 $25.00 510 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% Non Payable Non Payable 51945590 CLINIC UNLISTED CASTING/STRAPPING EACH 29799 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51953024 CLINIC UNLISTED PX MAT CARE&DLVR EACH 59899 $493.00 510 $345.10 $246.50 $394.40 65% 80% 50% 50% 65% Non Payable Non Payable 51921294 CLINIC UPPER GI ENDOSCOPY W/BIOPSY EACH 43239 "$2,242.00 " 750 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% Covered Charges NTE $1501/case $897 $815 $140.14 "$1,113 " "$1,113 " 51950814 CLINIC UPPER GI ENDOSCOPY W/FB REM EACH 43247 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 75102228 CLINIC UPPER GI ENDOSCOPY WITH TUBE EACH 43241 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% Covered Charges NTE $1501/case $897 $815 $143.41 "$1,113 " "$1,113 " 51921302 CLINIC UPPER GI ENDOSCOPY/LIGATION EACH 43244 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% Covered Charges NTE $1501/case $897 $815 $247.76 "$1,113 " "$1,113 " 51921286 CLINIC UPPR GI ENDOSCOPY DIAGNOSIS EACH 43235 "$2,242.00 " 750 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% Covered Charges NTE $1501/case $897 $815 $124.68 $824 $824 51946671 CLINIC UROFLOWMETRY CPLX EACH 51741 $777.00 510 $543.90 $388.50 $621.60 65% 80% 50% 50% 65% Non Payable Non Payable 51951911 CLINIC UROFLOWMETRYSMP EACH 51736 $316.00 920 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51947265 CLINIC VAG HYST INCLUDING T/O EACH 58262 "$12,298.00 " 510 "$8,608.60 " "$6,149.00 " "$9,838.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51947257 CLINIC VAGINAL HYSTERECTOMY EACH 58260 "$12,298.00 " 510 "$8,608.60 " "$6,149.00 " "$9,838.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51946846 CLINIC VASECT SEMEN EXAM EACH 55250 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51951713 CLINIC VENIPUNCTURECUTDOWN<1 EACH 36420 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51951721 CLINIC VENIPUNCTURECUTDOWN>1 EACH 36425 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51942852 CLINIC VERTEBROPLASTY-CERVICOTHOR EACH 22510 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51918258 CLINIC VISIT OP ESTAB LEVEL 1 EACH 99211 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918266 CLINIC VISIT OP ESTAB LEVEL 2 EACH 99212 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918274 CLINIC VISIT OP ESTAB LEVEL 3 EACH 99213 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918282 CLINIC VISIT OP ESTAB LEVEL 4 EACH 99214 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918290 CLINIC VISIT OP ESTAB LEVEL 5 EACH 99215 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918209 CLINIC VISIT OP NEW LEVEL 1 EACH 99201 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918217 CLINIC VISIT OP NEW LEVEL 2 EACH 99202 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918225 CLINIC VISIT OP NEW LEVEL 3 EACH 99203 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918233 CLINIC VISIT OP NEW LEVEL 4 EACH 99204 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51918241 CLINIC VISIT OP NEW LEVEL 5 EACH 99205 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51948891 CLINIC "VITRECTOMY, MECHANICAL " EACH 67040 "$10,053.00 " 510 "$7,037.10 " "$5,026.50 " "$8,042.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51949881 CLINIC WHOLE BODY PHOTOGRAPHY EACH 96904 $93.00 510 $65.10 $46.50 $74.40 65% 80% 50% 50% 65% Non Payable Non Payable 51945566 CLINIC WINDOWING OF CAST EACH 29730 $390.00 510 $273.00 $195.00 $312.00 65% 80% 50% 50% 65% Non Payable Non Payable 51941649 CLINIC WOUND PREP F/N/HF/G EACH 15004 "$1,553.00 " 510 "$1,087.10 " $776.50 "$1,242.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51941631 CLINIC WOUND PREP TRK/ARM/LEG EACH 15002 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51950004 CLINIC WOUND VAC 50 CM EACH 97608 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51941615 CLINIC XFER TISS EYE/EAR/LP <10CM EACH 14060 "$4,509.00 " 510 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 92904739 CLINICAL PSYCH 1ST PSYC COLLAB CARE MGMT EACH 99492 $221.00 929 $154.70 $110.50 $176.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904770 CLINICAL PSYCH 1ST/SBSQ PSYC COLLAB CARE EACH 99494 $41.00 929 $28.70 $20.50 $32.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904788 CLINICAL PSYCH ASSMT & CARE PLN PT COG IMP EACH 99483 $221.00 929 $154.70 $110.50 $176.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904457 CLINICAL PSYCH BRIEF EMOTIONAL/BEHAV ASSMT EACH 96127 $100.00 929 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904242 CLINICAL PSYCH ELECTROCONVULSIVE THERAPY EACH 90870 "$1,326.00 " 929 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904424 CLINICAL PSYCH EXM NEUROBH BY PSYCH 1ST HR EACH 96116 $777.00 929 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904432 CLINICAL PSYCH EXM NEUROBHVRL PSYC EA +HR EACH 96121 $111.00 929 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904358 CLINICAL PSYCH FUNCTIONAL BRAIN MAPPING EACH 96020 $50.00 929 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904598 CLINICAL PSYCH HEALTH/BEHAV EVAL/REEVAL EACH 96156 $221.00 929 $154.70 $110.50 $176.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904606 CLINICAL PSYCH HEALTH/BEHAV TX 1ST 30 MIN EACH 96158 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904630 CLINICAL PSYCH HEALTH/BEHAV TX ADD 15 MIN EACH 96159 $96.00 929 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904655 CLINICAL PSYCH HEALTH/BEHAV TX GRP +15 MIN EACH 96165 $37.00 929 $25.90 $18.50 $29.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904648 CLINICAL PSYCH HEALTH/BEHAV TX GRP 1ST 30M EACH 96164 $71.00 929 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904705 CLINICAL PSYCH HLTH/BEHAV TX FAM W/O PT 30 EACH 96170 $60.00 929 $42.00 $30.00 $48.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904671 CLINICAL PSYCH HLTH/BEHAV TX FAM W/PT +15M EACH 96168 $96.00 929 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904663 CLINICAL PSYCH HLTH/BEHAV TX FAM W/PT 30 M EACH 96167 $71.00 929 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904713 CLINICAL PSYCH HLTH/BEHAV TX FAM WO PT +15 EACH 96171 $30.00 929 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904002 CLINICAL PSYCH INTERACTIVE COMPLEXTY ADDON EACH 90785 $100.00 929 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904531 CLINICAL PSYCH NEUROPSYCH TEST ADMIN + 30 EACH 96137 $43.00 929 $30.10 $21.50 $34.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904523 CLINICAL PSYCH NEUROPSYCH TEST ADMIN 30 M EACH 96136 $316.00 929 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904507 CLINICAL PSYCH NEUROPSYCH TESTING 1ST HR EACH 96132 "$1,326.00 " 929 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904515 CLINICAL PSYCH NEUROPSYCH TESTING ADDL HR EACH 96133 $111.00 929 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904226 CLINICAL PSYCH PHARMACOLOGIC MGT W/PSYCOTH EACH 90863 $50.00 929 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904366 CLINICAL PSYCH PSY ASSESS APHASIA /HR EACH 96105 $234.00 929 $163.80 $117.00 $187.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904309 CLINICAL PSYCH PSY EVAL REC RPT TEST EACH 90885 $325.00 929 $227.50 $162.50 $260.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904317 CLINICAL PSYCH PSY INTERPRET FAMILY EACH 90887 $191.00 929 $133.70 $95.50 $152.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904234 CLINICAL PSYCH PSY NARCOSYNTHESIS EACH 90865 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904150 CLINICAL PSYCH PSY PSYCHOANLYS EACH 90845 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904580 CLINICAL PSYCH PSYC/NRPSYC TST AUTO RESULT EACH 96146 $74.00 929 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904010 CLINICAL PSYCH PSYCH DX EVAL EACH 90791 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904028 CLINICAL PSYCH PSYCH DX EVAL W/MED SERV EACH 90792 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904291 CLINICAL PSYCH PSYCH HYPNOTHRPY EACH 90880 $221.00 929 $154.70 $110.50 $176.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904721 CLINICAL PSYCH PSYCH PATIENT CARE CONF EACH 99366 $83.00 929 $58.10 $41.50 $66.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904259 CLINICAL PSYCH PSYCH THRPY BIOFEEDBK 20-30 EACH 90875 $100.00 929 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904283 CLINICAL PSYCH PSYCH THRPY BIOFEEDBK 45-50 EACH 90876 $189.00 929 $132.30 $94.50 $151.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904168 CLINICAL PSYCH PSYCH THRPY FAMILY W/O PT EACH 90846 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904176 CLINICAL PSYCH PSYCH THRPY FAMILY W/PT EACH 90847 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904218 CLINICAL PSYCH PSYCH THRPY GRP EACH 90853 $221.00 929 $154.70 $110.50 $176.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904184 CLINICAL PSYCH PSYCH THRPY GRP FAM MULTI EACH 90849 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904564 CLINICAL PSYCH PSYCH/NRPSYC TECH 1ST 30 EACH 96138 $986.00 929 $690.20 $493.00 $788.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904572 CLINICAL PSYCH PSYCH/NRPSYC TST TECH + 30 EACH 96139 $25.00 929 $17.50 $12.50 $20.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904499 CLINICAL PSYCH PSYCHOLOGICAL TESTING + HR EACH 96131 $111.00 929 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904465 CLINICAL PSYCH PSYCHOLOGICAL TESTING 1ST H EACH 96130 $777.00 929 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904044 CLINICAL PSYCH "PSYCHOTH, 30 MIN W/E&M " EACH 90833 $104.00 929 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904036 CLINICAL PSYCH "PSYCHOTH, 30 MINUTES " EACH 90832 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904085 CLINICAL PSYCH "PSYCHOTH, 45 MIN W/E&M " EACH 90836 $138.00 929 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904077 CLINICAL PSYCH "PSYCHOTH, 45 MINUTES " EACH 90834 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904101 CLINICAL PSYCH "PSYCHOTH, 60 MIN W/E&M " EACH 90838 $138.00 929 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904093 CLINICAL PSYCH "PSYCHOTH, 60 MINUTES " EACH 90837 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904119 CLINICAL PSYCH PSYCHOTHRPY CRISIS EACH 90839 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904143 CLINICAL PSYCH PSYCHOTHRPY CRISIS ADDL 30M EACH 90840 $138.00 929 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904325 CLINICAL PSYCH REPORT PREP - PSYCH STATUS EACH 90889 $50.00 929 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904747 CLINICAL PSYCH SBSQ PSYC COLLAB CARE MGMT EACH 99493 $395.00 929 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92904440 CLINICAL PSYCH STD COG TEST HC PRO PER HR EACH 96125 $244.00 929 $170.80 $122.00 $195.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51503472 CLINIC-OPHTHALMOLOGY A-SCAN BIOMETRY EACH 76516 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $45.55 Non Payable Non Payable 51503480 CLINIC-OPHTHALMOLOGY A-SCAN W/ IOL CALCULATION EACH 76519 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $62.77 Non Payable Non Payable 51503340 CLINIC-OPHTHALMOLOGY BIOPSY LACRIMAL GLAND EACH 68510 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503258 CLINIC-OPHTHALMOLOGY BIOPSY OF CONJUNCTIVA EACH 68100 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502961 CLINIC-OPHTHALMOLOGY BIOPSY OF EYELID EACH 67810 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503183 CLINIC-OPHTHALMOLOGY CANTHOPLASTY EACH 67950 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502920 CLINIC-OPHTHALMOLOGY CANTHOTOMY EACH 67715 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503357 CLINIC-OPHTHALMOLOGY CLEARANCE OF TEAR DUCT EACH 68530 $721.00 519 $504.70 $360.50 $576.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503407 CLINIC-OPHTHALMOLOGY CLOSE PUNCTUM LACRIMAL PLUG EACH 68761 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503621 CLINIC-OPHTHALMOLOGY CMPTR OPH DX IMG ANT SEG EACH 92132 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503753 CLINIC-OPHTHALMOLOGY COLOR VISION TESTING EACH 92283 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503530 CLINIC-OPHTHALMOLOGY COMPUTERIZED CORNEAL TOPOGR EACH 92025 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503290 CLINIC-OPHTHALMOLOGY CONJUNCTIVOPLAST CUL-DE-SAC EACH 68326 "$9,560.00 " 519 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503282 CLINIC-OPHTHALMOLOGY CONJUNCTIVOPLASTY W/GRAFT EACH 68320 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503571 CLINIC-OPHTHALMOLOGY CONTACT LENS FIT-KERATOCON EACH 92072 $23.00 510 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% Non Payable Non Payable 51503563 CLINIC-OPHTHALMOLOGY CONTACT LENS FITTING TX EACH 92071 $23.00 510 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% Non Payable Non Payable 51503662 CLINIC-OPHTHALMOLOGY CORNEAL HYSTERESIS DETER EACH 92145 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503100 CLINIC-OPHTHALMOLOGY CORRECT LID RETRACTION EACH 67911 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502979 CLINIC-OPHTHALMOLOGY CORRECT TRICHIASIS W/FORCEP EACH 67820 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502995 CLINIC-OPHTHALMOLOGY CORRECT TRICHIASIS W/GFT EACH 67835 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503399 CLINIC-OPHTHALMOLOGY CORRECTION EVERTED PUNCTUM EACH 68705 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503118 CLINIC-OPHTHALMOLOGY CORRECTION EYELID W/IMPLANT EACH 67912 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502599 CLINIC-OPHTHALMOLOGY DEST CILIARY BODY CRYOTHRPY EACH 66720 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502573 CLINIC-OPHTHALMOLOGY DEST CILIARY DIATHERMY EACH 66700 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502607 CLINIC-OPHTHALMOLOGY DEST CILIARYCYCLODIALYSIS EACH 66740 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502763 CLINIC-OPHTHALMOLOGY DEST LESN RETINAL CRYO/DIAT EACH 67208 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502771 CLINIC-OPHTHALMOLOGY DEST LESN RETINAL PHOTOCOAG EACH 67210 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502797 CLINIC-OPHTHALMOLOGY DEST RETINOPATHY EXTENSIVE EACH 67227 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502581 CLINIC-OPHTHALMOLOGY DESTR CILIARY BODY TRANSSCL EACH 66710 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502805 CLINIC-OPHTHALMOLOGY DESTRUCT EXT/PROG RETINOP EACH 67228 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503019 CLINIC-OPHTHALMOLOGY DESTRUCT LES-LID MARGN <1CM EACH 67850 "$2,504.00 " 510 "$1,752.80 " "$1,252.00 " "$2,003.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502789 CLINIC-OPHTHALMOLOGY DESTRUCT LOCAL LES CHOROID EACH 67220 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503498 CLINIC-OPHTHALMOLOGY DETERMINE REFRACTIVE STATE EACH 92015 $21.00 510 $14.70 $10.50 $16.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503415 CLINIC-OPHTHALMOLOGY DIL LACRIML PUNCTM W/WO IRR EACH 68801 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502631 CLINIC-OPHTHALMOLOGY DISCIS CATARACT SEC LASER EACH 66821 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502490 CLINIC-OPHTHALMOLOGY DRAIN EYE W/DX ASPIRATN EACH 65800 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503126 CLINIC-OPHTHALMOLOGY ECTROPION REP EXC TARSAL W EACH 67916 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503134 CLINIC-OPHTHALMOLOGY "ECTROPION REPAIR, EXTENSIVE" EACH 67917 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503746 CLINIC-OPHTHALMOLOGY ELECTRO-OCULOMYOGRAPH W/RPT EACH 92270 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503142 CLINIC-OPHTHALMOLOGY ENTROPION REP EXC TARSAL W EACH 67923 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503159 CLINIC-OPHTHALMOLOGY "ENTROPION REPAIR, EXTENSIVE" EACH 67924 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503506 CLINIC-OPHTHALMOLOGY EUA OPHTHALMOLOGICAL CMPL EACH 92018 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503514 CLINIC-OPHTHALMOLOGY EUA OPHTHALMOLOGICAL LTD EACH 92019 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503761 CLINIC-OPHTHALMOLOGY EXAM EYE DARK ADAPTATION EACH 92284 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502953 CLINIC-OPHTHALMOLOGY EXC CHALAZION MULT DIFF LID EACH 67805 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502946 CLINIC-OPHTHALMOLOGY EXC CHALAZION MULT SAME LID EACH 67801 "$2,504.00 " 510 "$1,752.80 " "$1,252.00 " "$2,003.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502938 CLINIC-OPHTHALMOLOGY EXC CHALAZION SGL EACH 67800 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503266 CLINIC-OPHTHALMOLOGY EXC LESN CONJUNC <1CM EACH 68110 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503001 CLINIC-OPHTHALMOLOGY EXC LESN EYELID NOT CHALAZ EACH 67840 "$2,504.00 " 510 "$1,752.80 " "$1,252.00 " "$2,003.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502664 CLINIC-OPHTHALMOLOGY EXCHG INTRAOCULAR LENS EACH 66986 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503274 CLINIC-OPHTHALMOLOGY EXCISION LESION CONJ >1 CM EACH 68115 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503779 CLINIC-OPHTHALMOLOGY EXTERNAL OCULAR PHOTOGRAPHY EACH 92285 $100.00 510 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% Non Payable Non Payable 51502185 CLINIC-OPHTHALMOLOGY EYE EXAM EST COMPREHENSIVE EACH 92014 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51502177 CLINIC-OPHTHALMOLOGY EYE EXAM EST INTERMEDIATE EACH 92012 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51502169 CLINIC-OPHTHALMOLOGY EYE EXAM NEW COMPREHENSIVE EACH 92004 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51502151 CLINIC-OPHTHALMOLOGY EYE EXAM NEW INTERMEDIATE EACH 92002 $327.00 510 $228.90 $163.50 $261.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503712 CLINIC-OPHTHALMOLOGY EYE EXAM W/FUNDUS PHOTO EACH 92250 $316.00 920 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51503688 CLINIC-OPHTHALMOLOGY EYE EXAM W/PHOTOS EACH 92230 "$1,326.00 " 510 $928.20 $663.00 "$1,060.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503928 CLINIC-OPHTHALMOLOGY EYE PROSTHESIS SERV EACH 92358 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503233 CLINIC-OPHTHALMOLOGY EYELID UNLSTD PROC EACH 67999 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502557 CLINIC-OPHTHALMOLOGY FIST SCLERA TRABECUL W/SCAR EACH 66172 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503696 CLINIC-OPHTHALMOLOGY FLUORESCEIN ANGIOGR W/S&I EACH 92235 $777.00 920 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51503522 CLINIC-OPHTHALMOLOGY GONIOSCOPY EACH 92020 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503704 CLINIC-OPHTHALMOLOGY ICG ANGIOGRAPHY EACH 92240 $777.00 510 $543.90 $388.50 $621.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503332 CLINIC-OPHTHALMOLOGY INCISE TEAR DUCT OPENING EACH 68440 $721.00 519 $504.70 $360.50 $576.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503324 CLINIC-OPHTHALMOLOGY INCISE/DRAIN TEAR SAC EACH 68420 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503241 CLINIC-OPHTHALMOLOGY INCISION CONJ/DRAINAGE CYST EACH 68020 "$2,504.00 " 510 "$1,752.80 " "$1,252.00 " "$2,003.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502912 CLINIC-OPHTHALMOLOGY INCISION OF EYELID EACH 67710 "$2,504.00 " 519 "$1,752.80 " "$1,252.00 " "$2,003.20 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502888 CLINIC-OPHTHALMOLOGY INJ AGENT THPY TENONS CAP EACH 67515 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502532 CLINIC-OPHTHALMOLOGY INJ ANT CHAMBER EYE AIR/LIQ EACH 66020 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502862 CLINIC-OPHTHALMOLOGY INJ MEDS RETROBULAR EACH 67500 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502201 CLINIC-OPHTHALMOLOGY INS IMPL OCUL P/ENUCL UNATT EACH 65135 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503787 CLINIC-OPHTHALMOLOGY INT EYE PHOTO EACH 92286 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503795 CLINIC-OPHTHALMOLOGY INT EYE PHOTO ANGIOGRAPHY EACH 92287 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502680 CLINIC-OPHTHALMOLOGY INTRAVITREAL EACH 67028 $838.00 510 $586.60 $419.00 $670.40 65% 80% 50% 50% 65% Non Payable Non Payable 51502565 CLINIC-OPHTHALMOLOGY IRIDECT W/COR REM LES EACH 66600 "$10,053.00 " 510 "$7,037.10 " "$5,026.50 " "$8,042.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502623 CLINIC-OPHTHALMOLOGY IRIDOPLASTY EACH 66762 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502615 CLINIC-OPHTHALMOLOGY IRIDOT/IREDECT LASER EACH 66761 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502482 CLINIC-OPHTHALMOLOGY KERATOPROSTHESIS EACH 65770 "$30,652.00 " 510 "$21,456.40 " "$15,326.00 " "$24,521.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502441 CLINIC-OPHTHALMOLOGY KERATPLASTY LAMELLAR EACH 65710 "$12,923.00 " 510 "$9,046.10 " "$6,461.50 " "$10,338.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502458 CLINIC-OPHTHALMOLOGY KERATPLASTY PENETRAT EACH 65730 "$10,053.00 " 510 "$7,037.10 " "$5,026.50 " "$8,042.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502466 CLINIC-OPHTHALMOLOGY KERATPLASTY PENETRAT APHAHI EACH 65750 "$12,923.00 " 510 "$9,046.10 " "$6,461.50 " "$10,338.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503860 CLINIC-OPHTHALMOLOGY MOD CONTACT LENS W/MD SUPER EACH 92325 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503423 CLINIC-OPHTHALMOLOGY NASOLACRIMAL DUCT PROBING EACH 68810 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503738 CLINIC-OPHTHALMOLOGY OCULOELECTROMYOGRAPHY EACH 92265 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503654 CLINIC-OPHTHALMOLOGY OPHTHALMIC BIOMETRY EACH 92136 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503720 CLINIC-OPHTHALMOLOGY OPHTHALMODYNAMOMETRY EACH 92260 $100.00 510 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% Non Payable Non Payable 51502896 CLINIC-OPHTHALMOLOGY ORBIT SURGERY PROCEDURE EACH 67599 $721.00 519 $504.70 $360.50 $576.80 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502854 CLINIC-OPHTHALMOLOGY ORBIT/BONE FLAP REM LES EACH 67420 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503449 CLINIC-OPHTHALMOLOGY PROBE CANALICULI W/WO IRRIG EACH 68840 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503431 CLINIC-OPHTHALMOLOGY PROBE NASOLACRIMAL DUCT EACH 68811 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502755 CLINIC-OPHTHALMOLOGY PROPHYL RETINAL PHOTOCOAG EACH 67145 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502748 CLINIC-OPHTHALMOLOGY PROPHYLAXIS RD CRYO/DIATHER EACH 67141 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503217 CLINIC-OPHTHALMOLOGY RECONSTRUCT EYELID TO 2/3 EACH 67971 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503225 CLINIC-OPHTHALMOLOGY RECONSTRUCT EYELID TOTAL EACH 67975 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503092 CLINIC-OPHTHALMOLOGY RED OVERCORRECTION PTOSIS EACH 67909 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502649 CLINIC-OPHTHALMOLOGY REM CATARACT SEC W/CORN-SCL EACH 66830 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502219 CLINIC-OPHTHALMOLOGY REM FB CONJUCT SUPERFIC EACH 65205 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51502250 CLINIC-OPHTHALMOLOGY REM FB INTRAOCUL ANT CHAMB EACH 65235 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502268 CLINIC-OPHTHALMOLOGY REM FB POST SEG MAG EXTRCT EACH 65260 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502276 CLINIC-OPHTHALMOLOGY REM FB POST SEG NONMAGNETIC EACH 65265 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502656 CLINIC-OPHTHALMOLOGY REM ICCR W/IOL INS EACH 66983 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503365 CLINIC-OPHTHALMOLOGY REMOVE TEAR GLAN FRONTAL EACH 68540 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503373 CLINIC-OPHTHALMOLOGY REMOVE TEAR GLAND OSTEOTOMY EACH 68550 "$9,560.00 " 519 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503076 CLINIC-OPHTHALMOLOGY REP EYELID DEF - EXTERNAL EACH 67904 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503084 CLINIC-OPHTHALMOLOGY REP EYELID DEF - FAS-SERVAT EACH 67908 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503068 CLINIC-OPHTHALMOLOGY REP EYELID DEF-BANK FASCIA EACH 67901 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503050 CLINIC-OPHTHALMOLOGY REPAIR BROW DEFECT EACH 67900 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503175 CLINIC-OPHTHALMOLOGY REPAIR EYELID WOUND EACH 67935 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503167 CLINIC-OPHTHALMOLOGY REPAIR EYELID WOUND THICK EACH 67930 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502730 CLINIC-OPHTHALMOLOGY REPAIR RD INJECTION AIR/GAS EACH 67110 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502706 CLINIC-OPHTHALMOLOGY REPAIR RETINAL DETACH CRYO EACH 67101 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503381 CLINIC-OPHTHALMOLOGY REPAIR TEAR DUCTS EACH 68700 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503878 CLINIC-OPHTHALMOLOGY REPLMNT CONTACT LENS EACH 92326 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51502813 CLINIC-OPHTHALMOLOGY RES STRABIS 2 MUSCLE HRZ EACH 67312 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502870 CLINIC-OPHTHALMOLOGY RETROBULBAR INJ - ALCOHOL EACH 67505 $721.00 510 $504.70 $360.50 $576.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503043 CLINIC-OPHTHALMOLOGY REV EYELID W/TARSAL PLATE EACH 67882 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502987 CLINIC-OPHTHALMOLOGY REVISE EYELASHES EACH 67830 "$2,504.00 " 519 "$1,752.80 " "$1,252.00 " "$2,003.20 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503308 CLINIC-OPHTHALMOLOGY REVISE EYELID LINING EACH 68330 "$5,762.00 " 519 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502193 CLINIC-OPHTHALMOLOGY REVISE OCULAR CONTENT EACH 65091 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503191 CLINIC-OPHTHALMOLOGY REVISION EYELID UP TO 1/4 EACH 67961 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503035 CLINIC-OPHTHALMOLOGY REVISION OF EYELID EACH 67880 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503209 CLINIC-OPHTHALMOLOGY REVISION OF EYELID > 1/4 EACH 67966 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502284 CLINIC-OPHTHALMOLOGY RPR LAC CONJUNCT CLOSE DIR EACH 65270 "$5,778.00 " 510 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502300 CLINIC-OPHTHALMOLOGY RPR LAC CONJUNCT W/HOSP EACH 65273 $508.44 510 $355.91 $254.22 $406.75 65% 80% 50% 50% 65% Non Payable Non Payable 51502326 CLINIC-OPHTHALMOLOGY RPR LAC CORNEA PERF EACH 65280 "$12,923.00 " 510 "$9,046.10 " "$6,461.50 " "$10,338.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502334 CLINIC-OPHTHALMOLOGY RPR LAC CORNEA RES TISS EACH 65285 "$12,923.00 " 510 "$9,046.10 " "$6,461.50 " "$10,338.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502318 CLINIC-OPHTHALMOLOGY RPR LAC CORNEA W/W/O REM EACH 65275 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502714 CLINIC-OPHTHALMOLOGY RPR RETINA DET PHOTOCOAG EACH 67105 "$1,438.00 " 510 "$1,006.60 " $719.00 "$1,150.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502722 CLINIC-OPHTHALMOLOGY RPR RETINA DET W/VITRECT EACH 67108 "$10,053.00 " 510 "$7,037.10 " "$5,026.50 " "$8,042.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502359 CLINIC-OPHTHALMOLOGY RPR WOUND EXTRAOCULAR EACH 65290 "$9,560.00 " 510 "$6,692.00 " "$4,780.00 " "$7,648.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503936 CLINIC-OPHTHALMOLOGY RPR/REFIT SPECTACLES APHAK EACH 92371 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503647 CLINIC-OPHTHALMOLOGY SCAN COMP DX IMAGE RETINA EACH 92134 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503639 CLINIC-OPHTHALMOLOGY SCAN DX IMAGE OPTIC NERVE EACH 92133 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503837 CLINIC-OPHTHALMOLOGY SCRIPT LENS 1 EYE APHAKIA EACH 92315 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503845 CLINIC-OPHTHALMOLOGY SCRIPT LENS 2 EYE APHAKIA EACH 92316 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503811 CLINIC-OPHTHALMOLOGY SCRIPT LENS 2 EYES APHAKIA EACH 92312 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503852 CLINIC-OPHTHALMOLOGY SCRIPT LENS CORNEOSCLERA EACH 92317 $100.00 510 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% Non Payable Non Payable 51503829 CLINIC-OPHTHALMOLOGY SCRIPT LENS CORNEOSCLERAL EACH 92313 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503803 CLINIC-OPHTHALMOLOGY SCRIPT/FIT LEN 1 EYE APHAKI EACH 92311 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 51503548 CLINIC-OPHTHALMOLOGY SENSORIMOTOR EXAM OCULAR EACH 92060 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503316 CLINIC-OPHTHALMOLOGY SEPARATE EYELID ADHESIONS EACH 68340 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503613 CLINIC-OPHTHALMOLOGY SERIAL TONOMETRY EACH 92100 $50.00 510 $35.00 $25.00 $40.00 65% 80% 50% 50% 65% Non Payable Non Payable 51502516 CLINIC-OPHTHALMOLOGY SEVER ADHES SYNECH POSTER EACH 65875 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503886 CLINIC-OPHTHALMOLOGY SPEC SPECT FT APH MON EACH 92352 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503894 CLINIC-OPHTHALMOLOGY SPEC SPECT FT APH MUL EACH 92353 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 51503910 CLINIC-OPHTHALMOLOGY SPEC SPECT FT COMP SY EACH 92355 $100.00 510 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% Non Payable Non Payable 51503902 CLINIC-OPHTHALMOLOGY SPEC SPECT FT SNGL SY EACH 92354 $100.00 510 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% Non Payable Non Payable 51503027 CLINIC-OPHTHALMOLOGY TEMP CLOSURE EYELIDS SUTURE EACH 67875 "$2,504.00 " 510 "$1,752.80 " "$1,252.00 " "$2,003.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51503555 CLINIC-OPHTHALMOLOGY TRAIN ORTHOPTIC/PLEOPTIC EACH 92065 $170.00 510 $119.00 $85.00 $136.00 65% 80% 50% 50% 65% Non Payable Non Payable 51502821 CLINIC-OPHTHALMOLOGY TRANSPOS PROC MUSC EXTRAOCU EACH 67320 "$4,479.00 " 510 "$3,135.30 " "$2,239.50 " "$3,583.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502847 CLINIC-OPHTHALMOLOGY TREAT EYE SOCKET W/REM FB EACH 67413 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51502839 CLINIC-OPHTHALMOLOGY TREAT EYE SOCKET W/REM LES EACH 67412 "$5,778.00 " 519 "$4,044.60 " "$2,889.00 " "$4,622.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 51503464 CLINIC-OPHTHALMOLOGY ULTRASOUND PACHYMETRY EACH 76514 $74.00 402 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $12.51 $12.51 $11.76 Non Payable Non Payable 51503456 CLINIC-OPHTHALMOLOGY US EYE B-SCAN EACH 76512 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $49.74 Non Payable Non Payable 51503605 CLINIC-OPHTHALMOLOGY VISUAL FIELD EXAM EXTEND EACH 92083 $316.00 920 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51503597 CLINIC-OPHTHALMOLOGY VISUAL FIELD EXAM INTERMED EACH 92082 $152.00 920 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51503589 CLINIC-OPHTHALMOLOGY VISUAL FIELD EXAM LIMITED EACH 92081 $152.00 920 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51502698 CLINIC-OPHTHALMOLOGY VITRECT W/FOCAL PHOTOCOAG EACH 67039 "$10,053.00 " 510 "$7,037.10 " "$5,026.50 " "$8,042.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 51502672 CLINIC-OPHTHALMOLOGY VITREOUS TAP EACH 67015 "$5,762.00 " 510 "$4,033.40 " "$2,881.00 " "$4,609.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 82000001 DIALYSIS DIALYSIS CAPD I/P EACH $322.49 803 $225.74 $161.25 $257.99 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000027 DIALYSIS DIALYSIS CCPD I/P EACH $515.00 804 $360.50 $257.50 $412.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000050 DIALYSIS DIALYSIS PERITON O/P 1 EVAL EACH 90945 "$1,096.00 " 831 $767.20 $548.00 $876.80 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000068 DIALYSIS DIALYSIS PERITONEAL I/P EACH $459.00 802 $321.30 $229.50 $367.20 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000076 DIALYSIS ESRD EMERGENCY DIALYSIS TX EACH G0257 "$1,728.00 " 829 "$1,209.60 " $864.00 "$1,382.40 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000142 DIALYSIS HEMODIALSIS FLOW STUDY O/P EACH 90940 $360.00 880 $252.00 $180.00 $288.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000233 DIALYSIS HEMODIALYSIS FINAL SESSION EACH 90999 "$1,338.00 " 821 $936.60 $669.00 "$1,070.40 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000159 DIALYSIS HEMODIALYSIS I/P EACH $545.00 801 $381.50 $272.50 $436.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000258 DIALYSIS HEMODIALYSIS NON RECURRING EACH 90935 "$1,728.00 " 820 "$1,209.60 " $864.00 "$1,382.40 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000175 DIALYSIS HEMODIALYSIS PROC REPEAT EACH 90937 "$1,338.00 " 821 $936.60 $669.00 "$1,070.40 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000191 DIALYSIS HEMOPERFUSION EACH 90997 $218.00 820 $152.60 $109.00 $174.40 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000449 DIALYSIS PD CAPD HOME ADMINISTRATION EACH 90947 $600.00 840 $420.00 $300.00 $480.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000423 DIALYSIS PD CAPD RETRAINING EACH 90993 "$1,400.00 " 840 $980.00 $700.00 "$1,120.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000407 DIALYSIS PD CAPD TRAINING EACH 90993 "$1,400.00 " 840 $980.00 $700.00 "$1,120.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000456 DIALYSIS PD CCPD HOME ADMINISTRATION EACH 90947 $600.00 850 $420.00 $300.00 $480.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000431 DIALYSIS PD CCPD RETRAINING EACH 90993 "$1,400.00 " 850 $980.00 $700.00 "$1,120.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 82000415 DIALYSIS PD CCPD TRAINING EACH 90993 "$1,400.00 " 850 $980.00 $700.00 "$1,120.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 92300003 DUPLEX DETERMINE VENOUS PRESSURE EACH 93770 $36.60 480 $25.62 $18.30 $29.28 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 92300300 DUPLEX DOPPLER ARTERIAL EXT CMPL EACH 93923 $387.00 921 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300037 DUPLEX DOPPLER ARTERIAL EXT W/STRESS EACH 93924 $387.00 921 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300052 DUPLEX DOPPLER INTRACRAN EMBOLI W/INJ EACH 93893 $272.00 920 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300060 DUPLEX DOPPLER INTRACRANIAL EMBOL W/O EACH 93892 $272.00 920 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300078 DUPLEX DOPPLER INTRACRANIAL VASOREACT EACH 93890 $606.00 920 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300086 DUPLEX DOPPLER TRANSCRANIAL CMPL EACH 93886 $606.00 920 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300094 DUPLEX DOPPLER TRANSCRANIAL LTD EACH 93888 $272.00 920 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300110 DUPLEX DUPLEX ABD/PEL/RETRO CMPL EACH 93975 $606.00 921 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300128 DUPLEX DUPLEX ABD/PEL/RETRO LTD EACH 93976 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300136 DUPLEX DUPLEX AORTA/IVC/GRAFT CMPL EACH 93978 $606.00 921 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300144 DUPLEX DUPLEX AORTA/IVC/GRAFT LTD EACH 93979 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300151 DUPLEX DUPLEX ART UPR EXT UNILAT/LMTD EACH 93931 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300169 DUPLEX DUPLEX ARTERIAL LWR EXT BILAT EACH 93925 $606.00 921 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300177 DUPLEX DUPLEX ARTERIAL UPR EXT BILAT EACH 93930 $606.00 921 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300185 DUPLEX DUPLEX ARTRL LWR EXT UNILT/LMT EACH 93926 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300193 DUPLEX DUPLEX EXTRACRANIAL BILAT EACH 93880 $606.00 921 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300201 DUPLEX DUPLEX EXTRACRANIAL UNILAT EACH 93882 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300219 DUPLEX DUPLEX HEMODIALYSIS ACCESS EACH 93990 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300227 DUPLEX DUPLEX PENILE VESSELS CMPL EACH 93980 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300235 DUPLEX DUPLEX PENILE VESSELS LTD EACH 93981 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300243 DUPLEX DUPLEX VENOUS EXT BILAT EACH 93970 $606.00 921 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300250 DUPLEX DUPLEX VENOUS EXT UNILAT/LMTD EACH 93971 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300318 DUPLEX DUP-SCAN HEMO COMPL STUDY BI EACH 93985 $606.00 921 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92300326 DUPLEX DUP-SCAN HEMO COMPL STUDY UNI EACH 93986 $272.00 921 $190.40 $136.00 $217.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 95900056 EDUCATION AND TRAINING CARDIAC REHAB W/EKG SESSION EACH 93798 $327.00 943 $228.90 $163.50 $261.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 95900064 EDUCATION AND TRAINING CARDIAC REHAB W/O EKG SESSION EACH 93797 $327.00 943 $228.90 $163.50 $261.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 95900007 EDUCATION AND TRAINING DIAB SELF MGT GRP O/P 30MIN EACH G0109 $39.00 942 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 95900015 EDUCATION AND TRAINING DIAB SELF MGT INDIV OP 30 MIN EACH G0108 $69.00 942 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 95900023 EDUCATION AND TRAINING NUTRITION THRPY EVAL 15 MIN EACH 97802 $79.00 942 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 95900031 EDUCATION AND TRAINING NUTRITION THRPY GROUP 30 MIN EACH 97804 $38.00 942 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 95900049 EDUCATION AND TRAINING NUTRITION THRPY RE-EVAL 15 MIN EACH 97803 $69.00 942 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 74900010 EEG EEG AWAKE/ASLEEP EACH 95819 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900028 EEG EEG AWAKE/DROWSY EACH 95816 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900036 EEG EEG CEREBRAL DEATH EVAL EACH 95824 "$1,326.00 " 740 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900044 EEG EEG COMA OR SLEEP ONLY EACH 95822 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900259 EEG EEG CONT REC W/VID EEG TECH EACH 95700 $387.00 740 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900051 EEG EEG CORTICAL MAP 1ST HR EACH 95961 "$2,586.00 " 740 "$1,810.20 " "$1,293.00 " "$2,068.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900069 EEG EEG CORTICAL MAP ADD HR EACH 95962 $484.00 740 $338.80 $242.00 $387.20 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900192 EEG EEG DIGITAL ANALYSIS EACH 95957 $276.00 740 $193.20 $138.00 $220.80 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900226 EEG EEG INTRAOP MONIT OUT OR 15MIN EACH 95940 "$1,318.00 " 920 $922.60 $659.00 "$1,054.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 74900218 EEG EEG INTRAOP MONITOR IN OR 1 HR EACH 95941 $600.00 920 $420.00 $300.00 $480.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 74900077 EEG EEG MONITOR > 1 HR EACH 95813 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900085 EEG EEG MONITOR 41-60 MIN EACH 95812 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900176 EEG EEG NON INTRACRANAIL SURGERY EACH 95955 $268.00 740 $187.60 $134.00 $214.40 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900267 EEG EEG W/O VID 2-12 HR UNMNTR EACH 95705 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900283 EEG EEG W/O VID 2-12HR CONT MNTR EACH 95707 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900309 EEG EEG W/O VID EA 12-26HR INTMT EACH 95710 "$1,326.00 " 740 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900374 EEG EEG W/O VID EA 12-26HR INTMT EACH 95709 "$1,326.00 " 740 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900168 EEG EEG W/PHARACEUTICAL ACTIVATION EACH 95954 "$1,326.00 " 740 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900275 EEG EEG WO VID 2-12HR INTMT MNTR EACH 95706 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900291 EEG EEG WO VID EA 12-26HR UNMNTR EACH 95708 "$1,326.00 " 740 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900234 EEG "EEG, WADA TEST " EACH 95958 "$2,586.00 " 740 "$1,810.20 " "$1,293.00 " "$2,068.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900101 EEG MEG EVOKED FIELDS EA ADD EACH 95967 "$2,619.00 " 740 "$1,833.30 " "$1,309.50 " "$2,095.20 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900119 EEG MEG EVOKED FIELDS SINGLE EACH 95966 "$2,586.00 " 740 "$1,810.20 " "$1,293.00 " "$2,068.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900127 EEG MEG SPONTANEOUS ACTIVITY EACH 95965 "$2,586.00 " 740 "$1,810.20 " "$1,293.00 " "$2,068.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900333 EEG VEEG 2-12 HR CONT MNTR EACH 95713 "$1,326.00 " 740 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900325 EEG VEEG 2-12 HR INTMT MNTR EACH 95712 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900317 EEG VEEG 2-12 HR UNMONITORED EACH 95711 $777.00 740 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900341 EEG VEEG EA 12-26 HR UNMNTR EACH 95714 "$1,326.00 " 740 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900366 EEG VEEG EA 12-26HR CONT MNTR EACH 95716 "$2,586.00 " 740 "$1,810.20 " "$1,293.00 " "$2,068.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 74900358 EEG VEEG EA 12-26HR INTMT MNTR EACH 95715 "$1,326.00 " 740 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges $440/visit $400/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 73000242 EKG EKG RHYTHM TRACING ONLY EACH 93041 $152.00 730 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 73000267 EKG EKG SIGNAL AVERAGED EACH 93278 $152.00 730 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 73000283 EKG EKG TRACE ONLY CMPNT INIT EXAM EACH G0404 $74.00 730 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 73000309 EKG EVENT RECORD/DISCON 24H/30D EACH 93270 $94.00 731 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 73000317 EKG EVENT TRANSMIT/ANLYS 24H/30D EACH 93271 $240.00 731 $168.00 $120.00 $192.00 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 73000424 EKG EXT ECG RECORDING CONNECTION EACH 0296T $100.00 730 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 73000432 EKG EXTERNAL ECG 3-21 DAYS REPORT EACH 0297T $228.00 730 $159.60 $114.00 $182.40 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 73000358 EKG HOLTER SCAN ANLYS 24 HR EACH 93226 $152.00 731 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 73000366 EKG HOLTER SCAN RECORDING 24 HR EACH 93225 $316.00 731 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 45006491 EMERGENCY/TRAUMA APPL LONG LEG SPLINT EACH 29505 $390.00 450 $273.00 $195.00 $312.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45005949 EMERGENCY/TRAUMA APPL SPLINT ARM LONG EACH 29105 $390.00 450 $273.00 $195.00 $312.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006434 EMERGENCY/TRAUMA APPLY LOWER LEG SPLINT EACH 29515 $390.00 450 $273.00 $195.00 $312.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45008018 EMERGENCY/TRAUMA AQUEOUS SHUNT EYE W/GRAFT EACH 66180 "$10,053.00 " 450 "$7,037.10 " "$5,026.50 " "$8,042.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006657 EMERGENCY/TRAUMA ASP FINE NDL W/O IMAGING GUIDE EACH 10021 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007218 EMERGENCY/TRAUMA CL TX RADIAL ULN SHAFT FRACT W EACH 25565 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007259 EMERGENCY/TRAUMA CL TX TRANS-SCAPH FRACT DISLOC EACH 25680 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007242 EMERGENCY/TRAUMA CL TX ULNAR STYLOID FRACTURE EACH 25650 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006616 EMERGENCY/TRAUMA CLEAR OUTER EAR CANAL EACH 69200 $316.00 450 $221.20 $158.00 $252.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006798 EMERGENCY/TRAUMA CLOSURE WOUND DEHIS SMP EACH 12020 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006574 EMERGENCY/TRAUMA CONTROL OF NOSEBLEED EACH 30901 $316.00 450 $221.20 $158.00 $252.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006707 EMERGENCY/TRAUMA DEBR SKIN 10% BODY SURFACE EACH 11000 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006442 EMERGENCY/TRAUMA DRAIN SKIN ABSCESS COMPLEX EACH 10061 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006392 EMERGENCY/TRAUMA DRAIN SKIN ABSCESS SIMPLE EACH 10060 $495.00 450 $346.50 $247.50 $396.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006517 EMERGENCY/TRAUMA DRAIN/INJECT JOINT/BURSA MAJOR EACH 20610 $733.00 450 $513.10 $366.50 $586.40 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45010006 EMERGENCY/TRAUMA ED POC US SHOCK EACH $812.00 402 $568.40 $406.00 $649.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable Non Payable Non Payable 45010022 EMERGENCY/TRAUMA ED POC US TRAUMA EACH $812.00 402 $568.40 $406.00 $649.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable Non Payable Non Payable 45097920 EMERGENCY/TRAUMA ED-ALVEOLOPLASTY EA QUADRANT EACH 41874 "$7,961.00 " 450 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097854 EMERGENCY/TRAUMA ED-BLADDER ASP W/SUPRAPB CATH EACH 51102 "$5,037.00 " 450 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097961 EMERGENCY/TRAUMA ED-CYSTOSCOPY AND URETER CATH EACH 52005 "$5,037.00 " 450 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095106 EMERGENCY/TRAUMA ED-DEBR SKIN EA ADD 10% BODY EACH 11001 $150.00 450 $105.00 $75.00 $120.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095114 EMERGENCY/TRAUMA ED-DEBRIDE SKIN AT FX SITE EACH 11010 "$1,740.00 " 450 "$1,218.00 " $870.00 "$1,392.00 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097912 EMERGENCY/TRAUMA ED-PIERCE SKULL IMPLANT DEV EACH 61210 "$13,682.00 " 450 "$9,577.40 " "$6,841.00 " "$10,945.60 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095064 EMERGENCY/TRAUMA ED-REMOVE FOREIGN BODY EACH 10121 "$4,009.00 " 450 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097987 EMERGENCY/TRAUMA ED-REPAIR MOUTH LAC 2.5+ CM EACH 40831 "$1,361.00 " 450 $952.70 $680.50 "$1,088.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096310 EMERGENCY/TRAUMA ED-TX DISLOC KNEE EACH 27550 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096187 EMERGENCY/TRAUMA ED-TX DISLOC KNUCKLE EACH 26700 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096161 EMERGENCY/TRAUMA ED-TX DISLOC THUMB EACH 26641 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006350 EMERGENCY/TRAUMA ER CRITICAL CARE 30-74 MIN EACH 99291 "$2,293.00 " 450 "$1,605.10 " "$1,146.50 " "$1,834.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case $523/case $475/case Non Payable Non Payable Non Payable 45006368 EMERGENCY/TRAUMA ER CRITICAL CARE ADD 30 MIN EACH 99292 $406.00 450 $284.20 $203.00 $324.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case $523/case $475/case Non Payable Non Payable Non Payable 45005774 EMERGENCY/TRAUMA ER INJECT TX/PROPH/DX INT-ARTE EACH 96373 $530.00 450 $371.00 $265.00 $424.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006301 EMERGENCY/TRAUMA ER LEVEL 1 EACH 99281 $225.00 450 $157.50 $112.50 $180.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case $523/case $475/case $157/case 152/Case 152/Case 45006319 EMERGENCY/TRAUMA ER LEVEL 2 EACH 99282 $417.00 450 $291.90 $208.50 $333.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case $523/case $475/case $185/case 180/Case 180/Case 45006327 EMERGENCY/TRAUMA ER LEVEL 3 EACH 99283 $733.00 450 $513.10 $366.50 $586.40 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case $523/case $475/case $336/case 326/Case 326/Case 45006335 EMERGENCY/TRAUMA ER LEVEL 4 EACH 99284 "$1,140.00 " 450 $798.00 $570.00 $912.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case $523/case $475/case $364/case 353/Case 353/Case 45006343 EMERGENCY/TRAUMA ER LEVEL 5 EACH 99285 "$1,637.00 " 450 "$1,145.90 " $818.50 "$1,309.60 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case $523/case $475/case $487/case 473/Case 473/Case 45006384 EMERGENCY/TRAUMA ER PROCEDURE EACH $250.00 450 $175.00 $125.00 $200.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case $523/case $475/case Non Payable Non Payable Non Payable 45006939 EMERGENCY/TRAUMA ESCHAROTOMY INITIAL EACH 16035 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006723 EMERGENCY/TRAUMA EVAC HEMATOMA SUBUNGAL EACH 11740 $316.00 450 $221.20 $158.00 $252.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006749 EMERGENCY/TRAUMA EXC WEDGE SKIN NAIL FOLD EACH 11765 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096559 EMERGENCY/TRAUMA FCT- APPLY STRAPPING TOES EACH 29550 $152.00 450 $106.40 $76.00 $121.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096351 EMERGENCY/TRAUMA FCT-CLTX POST ANKLE FX W/MNPJ EACH 27768 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096799 EMERGENCY/TRAUMA FCT-COLLECT BLOOD PORT/ACCESS EACH 36591 $316.00 450 $221.20 $158.00 $252.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095130 EMERGENCY/TRAUMA FCT-DEB MUSC/FASCIA 20 SQ CM/< EACH 11043 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097995 EMERGENCY/TRAUMA FCT-DESTRUCT LES PALATE/UVULA EACH 42160 "$7,961.00 " 450 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097433 EMERGENCY/TRAUMA FCT-DILATE URETHRA STRICTURE EACH 53620 "$1,689.00 " 450 "$1,182.30 " $844.50 "$1,351.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096914 EMERGENCY/TRAUMA FCT-DRAIN ABSC PALATE/UVULA EACH 42000 $604.00 450 $422.80 $302.00 $483.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096856 EMERGENCY/TRAUMA FCT-DRAIN ABSC/CYST MOUTH SMP EACH 40800 "$1,740.00 " 450 "$1,218.00 " $870.00 "$1,392.00 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096146 EMERGENCY/TRAUMA FCT-DRAIN FINGER ABSCESS CPL EACH 26011 "$4,009.00 " 450 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097110 EMERGENCY/TRAUMA FCT-DRAIN SCROTUM ABSCESS EACH 55100 "$4,009.00 " 450 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096286 EMERGENCY/TRAUMA FCT-DRAIN THIGH/KNEE LESION EACH 27301 "$7,026.00 " 450 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095965 EMERGENCY/TRAUMA FCT-DRAINAGE OF ARM BURSA EACH 23931 "$4,009.00 " 450 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096864 EMERGENCY/TRAUMA FCT-DRAINAGE OF MOUTH LESION EACH 40801 "$1,361.00 " 450 $952.70 $680.50 "$1,088.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095809 EMERGENCY/TRAUMA FCT-DRESS/DEBR BURN >10% LRG EACH 16030 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095825 EMERGENCY/TRAUMA FCT-INCISION OF BREAST LESION EACH 19020 "$4,009.00 " 450 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096708 EMERGENCY/TRAUMA FCT-INCISION OF WINDPIPE EACH 31603 "$3,771.00 " 450 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096823 EMERGENCY/TRAUMA FCT-INSERT NEEDLE BONE CAVITY EACH 36680 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096757 EMERGENCY/TRAUMA FCT-INTRO NDL/INTRACATH VEIN EACH 36000 $50.00 450 $35.00 $25.00 $40.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096674 EMERGENCY/TRAUMA FCT-LARYNGOSCOPY INDIRECT EACH 31505 $490.00 450 $343.00 $245.00 $392.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096955 EMERGENCY/TRAUMA FCT-NASAL/OROGASTRIC W/STENT EACH 43752 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45009131 EMERGENCY/TRAUMA FCT-PROCTOSIGMOIDOSCOPY DX EACH 45300 "$2,260.00 " 450 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097292 EMERGENCY/TRAUMA FCT-REM IMPACTED EAR WAX UNI EACH 69209 $152.00 450 $106.40 $76.00 $121.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097011 EMERGENCY/TRAUMA FCT-REMOVAL OF HEMORRHOID CLOT EACH 46320 "$2,918.00 " 450 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097128 EMERGENCY/TRAUMA FCT-REMOVAL OF SCROTUM LESION EACH 55120 "$5,037.00 " 450 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45008034 EMERGENCY/TRAUMA FCT-REMOVAL OF TESTIS EACH 54520 "$8,620.00 " 450 "$6,034.00 " "$4,310.00 " "$6,896.00 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096971 EMERGENCY/TRAUMA FCT-REMOVE RECTAL OBSTRUCTION EACH 45915 "$2,918.00 " 450 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45008125 EMERGENCY/TRAUMA FCT-REMOVE SUTR/STAPL WO ANES EACH 15853 $25.00 450 $17.50 $12.50 $20.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096872 EMERGENCY/TRAUMA FCT-REPAIR TONGUE ANTERIOR EACH 41250 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096898 EMERGENCY/TRAUMA FCT-REPAIR TONGUE COMPLEX EACH 41252 $604.00 450 $422.80 $302.00 $483.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096880 EMERGENCY/TRAUMA FCT-REPAIR TONGUE POSTERIOR EACH 41251 $604.00 450 $422.80 $302.00 $483.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097425 EMERGENCY/TRAUMA FCT-RPLC GTUBE REVJ GSTRST TRC EACH 43763 $612.00 450 $428.40 $306.00 $489.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095569 EMERGENCY/TRAUMA FCT-RPR LAC INT NECK >30.0CM EACH 12047 "$4,509.00 " 450 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095544 EMERGENCY/TRAUMA FCT-RPR LAC INT NECK 12.6-20.0 EACH 12045 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095551 EMERGENCY/TRAUMA FCT-RPR LAC INT NECK 20.1-30.0 EACH 12046 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095502 EMERGENCY/TRAUMA FCT-RPR LAC INT SCALP >30.0CM EACH 12037 "$4,509.00 " 450 "$3,156.30 " "$2,254.50 " "$3,607.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095494 EMERGENCY/TRAUMA FCT-RPR LAC INT SCALP 20.1-30 EACH 12036 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096211 EMERGENCY/TRAUMA FCT-TREAT ARTICULAR FRACT EA EACH 26742 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096021 EMERGENCY/TRAUMA FCT-TREAT ELBOW FRACTURE EACH 24620 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096229 EMERGENCY/TRAUMA FCT-TREAT FINGER FRACTURE EACH EACH 26755 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096237 EMERGENCY/TRAUMA FCT-TREAT FINGER FRACTURE EACH EACH 26765 "$8,004.00 " 450 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096054 EMERGENCY/TRAUMA FCT-TREAT FRACTURE OF RADIUS EACH 25505 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096062 EMERGENCY/TRAUMA FCT-TREAT FRACTURE OF ULNA EACH 25535 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096278 EMERGENCY/TRAUMA FCT-TREAT HIP ARTHRO DISLOC EACH 27265 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096260 EMERGENCY/TRAUMA FCT-TREAT HIP DISLOCATION EACH 27250 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095999 EMERGENCY/TRAUMA FCT-TREAT HUMERUS CONDYLAR FX EACH 24577 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095981 EMERGENCY/TRAUMA FCT-TREAT HUMERUS SHAFT FRACT EACH 24505 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096328 EMERGENCY/TRAUMA FCT-TREAT KNEE DISLOCAT W/AN EACH 27552 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096419 EMERGENCY/TRAUMA FCT-TREAT LOWER LEG FRACTURE EACH 27825 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096120 EMERGENCY/TRAUMA FCT-TREAT LUNATE DISLOCATION EACH 25690 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096153 EMERGENCY/TRAUMA FCT-TREAT METACARPAL FRACTURE EACH 26605 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096112 EMERGENCY/TRAUMA FCT-TREAT WRIST DISLOCATION EACH 25660 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095908 EMERGENCY/TRAUMA FCT-TREATMENT OF NOSE FRACTURE EACH 21320 "$7,961.00 " 450 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097441 EMERGENCY/TRAUMA FCT-TREATMENT OF PENIS LESION EACH 54220 $612.00 450 $428.40 $306.00 $489.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096302 EMERGENCY/TRAUMA FCT-TREATMENT OF THIGH FRACT EACH 27510 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096443 EMERGENCY/TRAUMA FCT-TX ANKLE FRACT CLOSED W EACH 28435 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096427 EMERGENCY/TRAUMA FCT-TX DISLOC ANKLE EACH 27840 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096252 EMERGENCY/TRAUMA FCT-TX FINGER DISLOCATION W AN EACH 26775 $665.00 450 $465.50 $332.50 $532.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095924 EMERGENCY/TRAUMA FCT-TX PROXIMAL HUMERUS FRACT EACH 23605 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45095957 EMERGENCY/TRAUMA FCT-TX SHOULDER DISLOCATION/FX EACH 23665 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45096294 EMERGENCY/TRAUMA FCT-TX THIGH SHAFT FRACTURE EACH 27502 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45005899 EMERGENCY/TRAUMA FIX FX PELVIC RING POST PERC EACH 27216 "$17,689.00 " 360 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,267 " "$1,152 " $882.34 "$1,266 " "$1,266 " 45097391 EMERGENCY/TRAUMA FTC-CLTX MED ANKLE FX W/MAN EACH 27762 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097409 EMERGENCY/TRAUMA FTC-PERICARDIOCENTESIS W/IMAGE EACH 33016 "$3,960.00 " 450 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097755 EMERGENCY/TRAUMA FTC-ULNA PROXIMAL END W/MAN EACH 24675 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007788 EMERGENCY/TRAUMA GASTRIC INTUBATION & ASP EACH 43753 $777.00 450 $543.90 $388.50 $621.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006673 EMERGENCY/TRAUMA I&D CYST PILONIDAL CPLX EACH 10081 "$1,740.00 " 450 "$1,218.00 " $870.00 "$1,392.00 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006665 EMERGENCY/TRAUMA I&D CYST PILONIDAL SMP EACH 10080 "$1,740.00 " 450 "$1,218.00 " $870.00 "$1,392.00 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007804 EMERGENCY/TRAUMA INC THROMBOSED HEMORRHOID EXT EACH 46083 $612.00 450 $428.40 $306.00 $489.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45005857 EMERGENCY/TRAUMA INS WIRE/PIN SKELETAL TRACTION EACH 20650 "$8,004.00 " 450 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006483 EMERGENCY/TRAUMA INSERT TEMP BLADDER CATH EACH 51702 $316.00 450 $221.20 $158.00 $252.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007663 EMERGENCY/TRAUMA LARYNGOSCOPY DIRECT DX EACH 31525 "$4,197.00 " 450 "$2,937.90 " "$2,098.50 " "$3,357.60 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007689 EMERGENCY/TRAUMA LARYNGOSCOPY FLEX W REM FB EACH 31577 "$1,010.00 " 450 $707.00 $505.00 $808.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006624 EMERGENCY/TRAUMA REMOVAL OF NAIL BED EACH 11750 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006541 EMERGENCY/TRAUMA REMOVE IMPACTED EAR WAX EACH 69210 $152.00 450 $106.40 $76.00 $121.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007747 EMERGENCY/TRAUMA REPAIR LIP FULL THCK VERM ONLY EACH 40650 "$1,361.00 " 450 $952.70 $680.50 "$1,088.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006426 EMERGENCY/TRAUMA REPAIR WND SIMPLE FACE <2.5CM EACH 12011 $495.00 450 $346.50 $247.50 $396.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006400 EMERGENCY/TRAUMA REPAIR WND SIMPLE S/N/T <2.5CM EACH 12001 $495.00 450 $346.50 $247.50 $396.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006533 EMERGENCY/TRAUMA REPR WND SIMPL FACE 2.6-5.0CM EACH 12013 $495.00 450 $346.50 $247.50 $396.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006459 EMERGENCY/TRAUMA REPR WND SIMPL S/N/T 2.6-7.5CM EACH 12002 $495.00 450 $346.50 $247.50 $396.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006913 EMERGENCY/TRAUMA RPR LAC CPLX FOREHD 2.6-7.5CM EACH 13132 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006921 EMERGENCY/TRAUMA RPR LAC CPLX FOREHD EA ADDL 5. EACH 13133 $269.00 450 $188.30 $134.50 $215.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006897 EMERGENCY/TRAUMA RPR LAC CPLX SCALP 1.1-2.5CM EACH 13120 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006905 EMERGENCY/TRAUMA RPR LAC CPLX SCALP 2.6-7.5CM EACH 13121 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006871 EMERGENCY/TRAUMA RPR LAC INT FACE 2.6-5.0CM EACH 12052 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006889 EMERGENCY/TRAUMA RPR LAC INT FACE 7.6-12.5CM EACH 12054 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006830 EMERGENCY/TRAUMA RPR LAC INT NECK 2.5CM OR LESS EACH 12041 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006848 EMERGENCY/TRAUMA RPR LAC INT NECK 2.6-7.5CM EACH 12042 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006855 EMERGENCY/TRAUMA RPR LAC INT NECK 7.6-12.5CM EACH 12044 "$1,553.00 " 450 "$1,087.10 " $776.50 "$1,242.40 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45005840 EMERGENCY/TRAUMA RPR LAC INT SCALP 12.6-20.0CM EACH 12035 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006822 EMERGENCY/TRAUMA RPR LAC INT SCALP/AX 7.6-12.5 EACH 12034 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006814 EMERGENCY/TRAUMA RPR LAC INT SCALP/AXIL 2.6-7.5 EACH 12032 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006806 EMERGENCY/TRAUMA RPR LAC INT SCLP/AXIL TO 2.5CM EACH 12031 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006772 EMERGENCY/TRAUMA RPR LAC SMP FACE 5.1-7.5CM EACH 12014 $495.00 450 $346.50 $247.50 $396.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006780 EMERGENCY/TRAUMA RPR LAC SMP FACE 7.6-12.5CM EACH 12015 $495.00 450 $346.50 $247.50 $396.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006764 EMERGENCY/TRAUMA RPR LAC SMP SCALP 12.6-20.0CM EACH 12005 $986.00 450 $690.20 $493.00 $788.80 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006756 EMERGENCY/TRAUMA RPR LAC SMP SCALP 7.6-12.5 CM EACH 12004 $495.00 450 $346.50 $247.50 $396.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007705 EMERGENCY/TRAUMA THORACOTOMY W/CARDIAC MASSAGE EACH 32160 "$1,617.00 " 450 "$1,131.90 " $808.50 "$1,293.60 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007697 EMERGENCY/TRAUMA TRACHEOSTOMY CRICOTHYROID MEMB EACH 31605 $604.00 450 $422.80 $302.00 $483.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45097730 EMERGENCY/TRAUMA TRAUMA TEAM RESPONSE EACH G0390 "$3,386.00 " 681 "$2,370.20 " "$1,693.00 " "$2,708.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $1501/case 50% of Billed Charges 50% of Billed Charges $1030/case $1000 Per Case $1000 Per Case 45097748 EMERGENCY/TRAUMA TRAUMA TEAM RESPONSE EACH G0390 "$3,386.00 " 681 "$2,370.20 " "$1,693.00 " "$2,708.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $1501/case 50% of Billed Charges 50% of Billed Charges $1030/case $1000 Per Case $1000 Per Case 45006566 EMERGENCY/TRAUMA TRT FX RADIUS/ULNA W/MANIP EACH 25605 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006632 EMERGENCY/TRAUMA TRT FX RADIUS/ULNA W/O MANIP EACH 25600 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007358 EMERGENCY/TRAUMA TX ACETABULUM FRACT WO MAN EACH 27220 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007051 EMERGENCY/TRAUMA TX ACROMIOCLAVIC DISLOC WO MAN EACH 23540 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007481 EMERGENCY/TRAUMA TX BIMALL ANKLE FRACT W AMN EACH 27810 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007044 EMERGENCY/TRAUMA TX CLAVICULAR FRACTURE WO MAN EACH 23500 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007143 EMERGENCY/TRAUMA TX CLOSED ELBOW DISLOC WO ANES EACH 24600 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007341 EMERGENCY/TRAUMA TX COCCYGEAL FRACTURE EACH 27200 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45005873 EMERGENCY/TRAUMA TX DISL ELBOW W/ANES CLSD EACH 24605 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45005907 EMERGENCY/TRAUMA TX DISL HIP TRAUMA W/ANES CLSD EACH 27252 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45005915 EMERGENCY/TRAUMA TX DISL PATELLAR W/ANES CLSD EACH 27562 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45005865 EMERGENCY/TRAUMA TX DISL SHLDR W/MAN/ANES CLSD EACH 23655 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007465 EMERGENCY/TRAUMA TX DISTAL FIB FRACT LAT W MAN EACH 27788 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007382 EMERGENCY/TRAUMA TX FEM FRACT DISTAL END WO MAN EACH 27508 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007366 EMERGENCY/TRAUMA TX FEM FRACT PROX NECK WO EACH 27230 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45006996 EMERGENCY/TRAUMA TX FRACT ORBIT EXC BO WO MAN EACH 21400 "$1,361.00 " 450 $952.70 $680.50 "$1,088.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007556 EMERGENCY/TRAUMA TX FX ANKLE TALUS W/O MANIP EACH 28430 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007085 EMERGENCY/TRAUMA TX GR HUMERL TUBER FRAC WO MAN EACH 23620 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007374 EMERGENCY/TRAUMA TX GREAT TROCHANT FRACT WO MAN EACH 27246 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007135 EMERGENCY/TRAUMA TX HUMERAL EPI FRACT MED/LAT EACH 24560 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007127 EMERGENCY/TRAUMA TX HUMERAL FRACTURE WO MAN EACH 24530 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007119 EMERGENCY/TRAUMA TX HUMERAL SHAFT FRACT WO MAN EACH 24500 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007002 EMERGENCY/TRAUMA TX MANDIBULAR FRACTURE WO MAN EACH 21450 "$1,361.00 " 450 $952.70 $680.50 "$1,088.80 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007077 EMERGENCY/TRAUMA TX PROXIMAL HUMERAL FRACTURE EACH 23600 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007168 EMERGENCY/TRAUMA TX RADIAL HEAD NECK FRACT EACH 24650 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007150 EMERGENCY/TRAUMA TX RADIAL HEAD SUBLUX CH W MAN EACH 24640 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007069 EMERGENCY/TRAUMA TX SCAPULAR FRACTURE WO MAN EACH 23570 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007093 EMERGENCY/TRAUMA TX SHLDER DISLOC W/MAN WO ANES EACH 23650 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007010 EMERGENCY/TRAUMA TX TEMPOROMANDIBULAR DISLOC EACH 21480 $0.00 450 $0.00 $0.00 $0.00 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007507 EMERGENCY/TRAUMA TX TRIMALL ANKLE FRACT W MAN EACH 27818 "$3,974.00 " 450 "$2,781.80 " "$1,987.00 " "$3,179.20 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 45007176 EMERGENCY/TRAUMA TX ULNAR FRACT PROXIMAL WO MAN EACH 24670 $584.00 450 $408.80 $292.00 $467.20 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $423/case Non Payable Non Payable Non Payable Non Payable Non Payable 92200005 EMG AUTONOMIC FUNCTION CARDIOVAGAL EACH 95921 $387.00 922 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200013 EMG AUTONOMIC FUNCTION SUDOMOTOR EACH 95923 $316.00 922 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200021 EMG AUTONOMIC FUNCTION VASOMOTOR EACH 95922 $316.00 922 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200344 EMG BLINK REFLEX TEST EACH 95933 $152.00 920 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200732 EMG "BOTOX, FACE AND NECK, LEFT " EACH 64615 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 92200369 EMG CHEM/DEST NRV MUSCLE FACIAL EACH 64612 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 92200559 EMG CHEMODEN ADD'L EXTREM 1-4 MUSC EACH 64643 $225.00 510 $157.50 $112.50 $180.00 65% 80% 50% 50% 65% Non Payable Non Payable 92200575 EMG CHEMODEN EA ADD EXTREM 5+ MUSC EACH 64645 $225.00 510 $157.50 $112.50 $180.00 65% 80% 50% 50% 65% Non Payable Non Payable 92200534 EMG CHEMODEN LARYNX UNIL INC EMG EACH 64617 "$1,710.00 " 922 "$1,197.00 " $855.00 "$1,368.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200526 EMG CHEMODEN NECK MUSCLES EACH 64616 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 92200583 EMG CHEMODEN TRUNK MUSCLE 1-5 MUSC EACH 64646 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 92200591 EMG CHEMODEN TRUNK MUSCLE 6+ MUSC EACH 64647 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 92200567 EMG CHEMODEN1 EXTREM 5+ MUSCLES EACH 64644 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 92200393 EMG CHEMODENERVATION ECCRINE BOTH EACH 64650 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 92200401 EMG CHEMODENERVATION OTHER AREA(S) EACH 64653 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 92200039 EMG CMEP LWR LIMBS EACH 95929 "$1,326.00 " 920 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200443 EMG CMEP UPPER & LOWER LIMBS EACH 95939 "$2,586.00 " 929 "$1,810.20 " "$1,293.00 " "$2,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200047 EMG CMEP UPR LIMBS EACH 95928 "$2,586.00 " 920 "$1,810.20 " "$1,293.00 " "$2,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200104 EMG DYNAMIC SURFACE EMG EACH 96002 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200054 EMG ELEC STIM FOR GUID W/CHEMODEN EACH 95873 $124.00 922 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200294 EMG EMG 3 EXTREMITIES EACH 95863 $387.00 922 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200062 EMG EMG ANAL/URETHRAL SPHINCTER EACH 51784 $387.00 922 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200070 EMG EMG CRANIAL NERVE BILAT EACH 95868 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200088 EMG EMG CRANIAL NERVE UNILAT EACH 95867 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200096 EMG EMG DYNAMIC FINE WIRE 1 MUSC EACH 96003 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200112 EMG EMG FOUR EXTREMITIES EACH 95864 $387.00 922 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200120 EMG EMG HEMIDIAPHRAGM EACH 95866 $387.00 922 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200138 EMG EMG ISCHEMIC LIMB EXERCISE EACH 95875 $387.00 922 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200153 EMG EMG LARYNX EACH 95865 $316.00 922 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200310 EMG EMG LIMITED STUDY EACH 95870 $316.00 922 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200351 EMG EMG NDL ANAL/URETHRAL SPHINTER EACH 51785 $612.00 922 $428.40 $306.00 $489.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200161 EMG EMG NDLE FOR GUID W/CHEMODEN EACH 95874 $114.00 922 $79.80 $57.00 $91.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200179 EMG EMG ONE EXTREMITY EACH 95860 $316.00 922 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200187 EMG EMG SINGLE FIBER DENSITY EACH 95872 $387.00 922 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200302 EMG EMG THORASIC PARASPINAL EACH 95869 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200195 EMG EMG TWO EXTREMITIES EACH 95861 $316.00 922 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200625 EMG "EMG, NON-LIMB MUSCLE " EACH 95887 $160.00 922 $112.00 $80.00 $128.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200203 EMG EVOKED POTENTIAL VISUAL EACH 95930 $777.00 920 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200336 EMG MOTOR/SENS NRVE CONDUCT TEST EACH 95905 $986.00 922 $690.20 $493.00 $788.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200617 EMG MUSC TEST DONE W/N TEST COMP EACH 95886 $498.00 922 $348.60 $249.00 $398.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200609 EMG MUSC TST DONE W/NERV TST LIM EACH 95885 $313.00 922 $219.10 $156.50 $250.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200450 EMG NERVE CONDUCTION STUDIES; 1-2 EACH 95907 $387.00 922 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200518 EMG NERVE CONDUCTION STUDIES; 13+ EACH 95913 "$1,326.00 " 922 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200468 EMG NERVE CONDUCTION STUDIES; 3-4 EACH 95908 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200476 EMG NERVE CONDUCTION STUDIES; 5-6 EACH 95909 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200484 EMG NERVE CONDUCTION STUDIES; 7-8 EACH 95910 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200492 EMG NERVE CONDUCTION STUDIES; 9-10 EACH 95911 "$1,326.00 " 922 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200500 EMG NERVE CONDUCTION STUDIES;11-12 EACH 95912 "$1,326.00 " 922 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200252 EMG NEUROMUSCULAR JUNCTION TEST EACH 95937 $387.00 922 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200740 EMG QUAN PUPLMTRY PHY/QHP UNI/BI EACH 95919 $316.00 922 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200260 EMG SSEP LOWER LIMBS EACH 95926 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200278 EMG SSEP TRUNK/HEAD EACH 95927 $777.00 929 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200435 EMG SSEP UPPER & LOWER LIMBS EACH 95938 "$1,326.00 " 929 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200286 EMG SSEP UPPER LIMBS EACH 95925 $777.00 922 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92200757 EMG US NRV&ACC STRUX 1XTR COMPRE EACH 76883 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $85.50 $85.50 Non Payable Non Payable Non Payable 75102673 ENDOSCOPY COLONOSCOPY AND BIOPSY EACH 45380 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $203.37 "$1,113 " "$1,113 " 75102731 ENDOSCOPY COLONOSCOPY DILATE STRICTURE EACH 45386 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $214.80 "$1,113 " "$1,113 " 75102681 ENDOSCOPY COLONOSCOPY SUBMUCOUS INJ EACH 45381 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $203.37 "$1,113 " "$1,113 " 75102756 ENDOSCOPY COLONOSCOPY W/ENDOSCOPE US EACH 45391 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $259.89 "$1,113 " "$1,113 " 75102764 ENDOSCOPY COLONOSCOPY W/ENDOSCOPIC FNB EACH 45392 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $307.68 "$1,113 " "$1,113 " 75102665 ENDOSCOPY COLONOSCOPY W/FB REMOVAL EACH 45379 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $243.25 "$1,113 " "$1,113 " 75102715 ENDOSCOPY COLONOSCOPY W/HOT BIOP OR CAUT EACH 45384 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $234.39 "$1,113 " "$1,113 " 75102699 ENDOSCOPY COLONOSCOPY/CONTROL BLEEDING EACH 45382 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $262.12 "$1,113 " "$1,113 " 75102939 ENDOSCOPY EGD BALLOON DIL ESOPH30 MM/> EACH 43233 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $235.35 "$1,781 " "$1,781 " 75102954 ENDOSCOPY EGD ENDO MUCOSAL RESECTION EACH 43254 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $272.99 "$1,266 " "$1,266 " 75102962 ENDOSCOPY EGD ENDOSCOPIC STENT PLACE EACH 43266 "$14,092.00 " 750 "$9,864.40 " "$7,046.00 " "$11,273.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,267 " "$1,152 " $221.84 "$2,526 " "$2,526 " 75102970 ENDOSCOPY EGD LESION ABLATION EACH 43270 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $227.05 "$1,781 " "$1,781 " 75102947 ENDOSCOPY EGD US TRANSMURAL INJXN/MARK EACH 43253 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $266.10 "$1,781 " "$1,781 " 75102509 ENDOSCOPY ENDOSCOPIC PANCREATOSCOPY EACH 43273 "$4,583.00 " 750 "$3,208.10 " "$2,291.50 " "$3,666.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $88 $80 $121.90 "$2,526 " "$2,526 " 75102384 ENDOSCOPY ENDOSCOPIC ULTRASOUND EXAM EACH 43259 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $228.43 "$1,266 " "$1,266 " 75102186 ENDOSCOPY ENDOSCOPIC US EXAM ESOPH EACH 43237 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $197.28 "$1,113 " "$1,113 " 75103101 ENDOSCOPY ENDOSCOPY PROCEDURE 1ST HOUR FIRST 60 MINUTES "$2,990.00 " 750 "$2,093.00 " "$1,495.00 " "$2,392.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 75103101 ENDOSCOPY ENDOSCOPY PROCEDURE EACH ADDL 30 MINUTES EACH ADDL 30 MINUTES "$2,990.00 " 750 "$2,093.00 " "$1,495.00 " "$2,392.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 75103127 ENDOSCOPY ENDOSCOPY PROCEDURE-LEVEL 2 EA ADDL 30 MINUTES EACH ADDL 30 MINUTES "$4,485.00 " 750 "$3,139.50 " "$2,242.50 " "$3,588.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 75103127 ENDOSCOPY ENDOSCOPY PROCEDURE-LEVEL 2 FIRST HOUR FIRST 60 MINUTES "$4,485.00 " 750 "$3,139.50 " "$2,242.50 " "$3,588.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 75102392 ENDOSCOPY ERCP DIAGNOSTIC EACH 43260 "$9,470.00 " 750 "$6,629.00 " "$4,735.00 " "$7,576.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $325.79 "$1,113 " "$1,113 " 75103010 ENDOSCOPY ERCP EA DUCT/AMPULLA DILATE EACH 43277 "$9,470.00 " 750 "$6,629.00 " "$4,735.00 " "$7,576.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $382.17 "$2,526 " "$2,526 " 75103028 ENDOSCOPY ERCP LESION ABLATE W/DILATE EACH 43278 "$9,470.00 " 750 "$6,629.00 " "$4,735.00 " "$7,576.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $438.18 "$2,526 " "$2,526 " 75103002 ENDOSCOPY ERCP STENT EXCHANGE W/DILATE EACH 43276 "$14,092.00 " 750 "$9,864.40 " "$7,046.00 " "$11,273.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $486.14 "$2,526 " "$2,526 " 75102400 ENDOSCOPY ERCP W/ BIOPSY (S) EACH 43261 "$9,470.00 " 750 "$6,629.00 " "$4,735.00 " "$7,576.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $341.24 "$1,113 " "$1,113 " 75102426 ENDOSCOPY ERCP W/PRESSURE MEASUREMENT EACH 43263 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $359.96 "$1,113 " "$1,113 " 75102442 ENDOSCOPY ERCP W/RETROGRADE DESTRUCTION EACH 43265 "$14,092.00 " 750 "$9,864.40 " "$7,046.00 " "$11,273.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $437.89 "$1,113 " "$1,113 " 75102418 ENDOSCOPY ERCP W/SPHINCTERO/PAPILLOTOMY EACH 43262 "$9,470.00 " 750 "$6,629.00 " "$4,735.00 " "$7,576.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $359.96 "$1,113 " "$1,113 " 75102210 ENDOSCOPY ESOPH ENDOSCOPE W/DRAIN CYST EACH 43240 "$14,092.00 " 750 "$9,864.40 " "$7,046.00 " "$11,273.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $397.15 "$1,113 " "$1,113 " 75102301 ENDOSCOPY ESOPH ENDOSCOPY DILATION EACH 43249 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $155.21 "$1,113 " "$1,113 " 75102913 ENDOSCOPY ESOPHAGOSC DILATE BALLOON 30 EACH 43214 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $195.76 "$1,781 " "$1,781 " 75102871 ENDOSCOPY ESOPHAGOSC FLEX TRNSN BIOPY EACH 43198 "$2,242.00 " 750 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $102.00 "$1,266 " "$1,266 " 75102889 ENDOSCOPY ESOPHAGOSCOP MUCOSAL RESECT EACH 43211 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $236.65 "$1,266 " "$1,266 " 75102863 ENDOSCOPY ESOPHAGOSCOPY FLEX DX BRUSH EACH 43197 "$2,242.00 " 750 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $86.49 "$1,266 " "$1,266 " 75102921 ENDOSCOPY ESOPHAGOSCOPY LESION ABLATE EACH 43229 "$9,470.00 " 750 "$6,629.00 " "$4,735.00 " "$7,576.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $200.68 "$2,526 " "$2,526 " 75102905 ENDOSCOPY ESOPHAGOSCOPY RETRO BALLOON EACH 43213 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $265.78 "$1,781 " "$1,781 " 75102848 ENDOSCOPY ESOPHAGOSCOPY RIGID BALLOON EACH 43195 "$9,470.00 " 750 "$6,629.00 " "$4,735.00 " "$7,576.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $187.19 "$1,781 " "$1,781 " 75102806 ENDOSCOPY ESOPHAGOSCOPY RIGID TRNSO DX EACH 43191 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $156.84 "$1,266 " "$1,266 " 75102855 ENDOSCOPY ESOPHAGOSCP GUIDE WIRE DILAT EACH 43196 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $199.05 "$1,781 " "$1,781 " 75102822 ENDOSCOPY ESOPHAGOSCP RIG TRNSO BIOPSY EACH 43193 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $171.84 "$1,781 " "$1,781 " 75102814 ENDOSCOPY ESOPHAGOSCP RIG TRNSO INJECT EACH 43192 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $172.18 "$1,781 " "$1,781 " 75102830 ENDOSCOPY ESOPHAGOSCP RIG TRNSO REM FB EACH 43194 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $198.94 "$1,781 " "$1,781 " 75103069 ENDOSCOPY REMOVE FOREIGN BODY ADBOMEN EACH 49402 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% of Billed Charges 80% 50% Non Payable 65% Non Payable Non Payable 75102608 ENDOSCOPY SIG W/BALLOON DILATION EACH 45340 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $78.84 $824 $824 75102574 ENDOSCOPY SIGMOIDOSCOPY & DECOMPRESS EACH 45337 "$2,260.00 " 750 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $118.20 $824 $824 75102541 ENDOSCOPY SIGMOIDOSCOPY & POLYPECTOMY EACH 45333 "$2,260.00 " 750 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $660 $600 $96.08 $824 $824 75102558 ENDOSCOPY SIGMOIDOSCOPY FOR BLEEDING EACH 45334 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $118.53 $824 $824 75102533 ENDOSCOPY SIGMOIDOSCOPY W/FB REMOVAL EACH 45332 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $107.57 $824 $824 75102566 ENDOSCOPY SIGMOIDOSCOPY W/SUBMUC INJ EACH 45335 "$2,260.00 " 750 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $660 $600 $67.07 $824 $824 75102582 ENDOSCOPY SIGMOIDOSCOPY W/TUMOR REMOVE EACH 45338 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $122.36 $824 $824 75102616 ENDOSCOPY SIGMOIDOSCOPY W/ULTRASOUND EACH 45341 "$2,260.00 " 750 "$1,582.00 " "$1,130.00 " "$1,808.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $125.11 $824 $824 75102624 ENDOSCOPY SIGMOIDOSCOPY W/US GUIDE BX EACH 45342 "$2,918.00 " 750 "$2,042.60 " "$1,459.00 " "$2,334.40 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $171.05 $824 $824 75102004 ENDOSCOPY TRACHEOBRONCHOSCOPY EACH 31615 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% of Billed Charges 80% 50% 50% 65% Non Payable Non Payable 75102343 ENDOSCOPY UPPER GI ENDO W/CNT BLEEDING EACH 43255 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $202.81 "$1,113 " "$1,113 " 75102244 ENDOSCOPY UPPER GI ENDOSCOPY & INJECT EACH 43243 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $240.40 "$1,113 " "$1,113 " 75102327 ENDOSCOPY UPPER GI ENDOSCOPY W/SNARE EACH 43251 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $198.79 "$1,113 " "$1,113 " 75102194 ENDOSCOPY UPPER GI ENDOSCOPY W/US FN BX EACH 43238 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $234.33 "$1,113 " "$1,113 " 75102293 ENDOSCOPY UPPER GI ENDOSCOPY/GUIDE WIRE EACH 43248 "$2,242.00 " 750 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $167.41 "$1,113 " "$1,113 " 75102319 ENDOSCOPY UPPER GI ENDOSCOPY/TUMOR EACH 43250 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $176.09 "$1,113 " "$1,113 " 75102335 ENDOSCOPY UPPER GI OPTICL ENDOMICRSCOPY EACH 43252 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $172.13 "$1,781 " "$1,781 " 75102178 ENDOSCOPY UPPER GI SCOPE W/SUBMUC INJ EACH 43236 "$2,242.00 " 750 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $139.86 "$1,113 " "$1,113 " 75102368 ENDOSCOPY UPPER GI SCOPE W/THRML TXMNT EACH 43257 "$9,470.00 " 750 "$6,629.00 " "$4,735.00 " "$7,576.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case "$1,023 " $930 $238.20 "$1,266 " "$1,266 " 75102236 ENDOSCOPY UPPR GI ENDOSCOPY W/US FN BX EACH 43242 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $264.87 "$1,113 " "$1,113 " 75102269 ENDOSCOPY UPPR GI SCOPE DILATE STRICTR EACH 43245 "$4,705.00 " 750 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% of Billed Charges 80% Covered Charges NTE $1501/case $897 $815 $179.87 "$1,113 " "$1,113 " 75102772 ENDOSCOPY X-RAY BILE DUCT ENDOSCOPY EACH 74328 "$1,042.00 " 320 $729.40 $521.00 $833.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $115.93 65% of Billed Charges 65% of Billed Charges 27811041 IMPLANTS ADAPT/EXT LEAD LVL 0 EACH C1883 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811058 IMPLANTS ADAPT/EXT LEAD LVL 1 EACH C1883 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811140 IMPLANTS ADAPT/EXT LEAD LVL 10 EACH C1883 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811066 IMPLANTS ADAPT/EXT LEAD LVL 2 EACH C1883 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811074 IMPLANTS ADAPT/EXT LEAD LVL 3 EACH C1883 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811082 IMPLANTS ADAPT/EXT LEAD LVL 4 EACH C1883 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811090 IMPLANTS ADAPT/EXT LEAD LVL 5 EACH C1883 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811108 IMPLANTS ADAPT/EXT LEAD LVL 6 EACH C1883 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811116 IMPLANTS ADAPT/EXT LEAD LVL 7 EACH C1883 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811124 IMPLANTS ADAPT/EXT LEAD LVL 8 EACH C1883 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811132 IMPLANTS ADAPT/EXT LEAD LVL 9 EACH C1883 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802891 IMPLANTS ANCHOR LVL 0 EACH C1713 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802909 IMPLANTS ANCHOR LVL 1 EACH C1713 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802990 IMPLANTS ANCHOR LVL 10 EACH C1713 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802917 IMPLANTS ANCHOR LVL 2 EACH C1713 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802925 IMPLANTS ANCHOR LVL 3 EACH C1713 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802933 IMPLANTS ANCHOR LVL 4 EACH C1713 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802941 IMPLANTS ANCHOR LVL 5 EACH C1713 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802958 IMPLANTS ANCHOR LVL 6 EACH C1713 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802966 IMPLANTS ANCHOR LVL 7 EACH C1713 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802974 IMPLANTS ANCHOR LVL 8 EACH C1713 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802982 IMPLANTS ANCHOR LVL 9 EACH C1713 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812767 IMPLANTS ANTERIOR CHAMBER IOL LVL 0 EACH V2630 $75.00 276 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812775 IMPLANTS ANTERIOR CHAMBER IOL LVL 1 EACH V2630 $150.00 276 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812783 IMPLANTS ANTERIOR CHAMBER IOL LVL 2 EACH V2630 $300.00 276 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812791 IMPLANTS ANTERIOR CHAMBER IOL LVL 3 EACH V2630 $600.00 276 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812809 IMPLANTS ANTERIOR CHAMBER IOL LVL 4 EACH V2630 "$1,200.00 " 276 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812817 IMPLANTS ANTERIOR CHAMBER IOL LVL 5 EACH V2630 "$2,400.00 " 276 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27801091 IMPLANTS AO ELASTIC PREFAB EACH $119.25 270 $83.48 $59.63 $95.40 65% 80% 50% 50% 65% 65% 65% 27817261 IMPLANTS APLIGRAF LVL 0 EACH Q4101 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817279 IMPLANTS APLIGRAF LVL 1 EACH Q4101 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817360 IMPLANTS APLIGRAF LVL 10 EACH Q4101 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817287 IMPLANTS APLIGRAF LVL 2 EACH Q4101 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817295 IMPLANTS APLIGRAF LVL 3 EACH Q4101 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817303 IMPLANTS APLIGRAF LVL 4 EACH Q4101 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817311 IMPLANTS APLIGRAF LVL 5 EACH Q4101 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817329 IMPLANTS APLIGRAF LVL 6 EACH Q4101 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817337 IMPLANTS APLIGRAF LVL 7 EACH Q4101 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817345 IMPLANTS APLIGRAF LVL 8 EACH Q4101 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817352 IMPLANTS APLIGRAF LVL 9 EACH Q4101 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814789 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 0 EACH C1783 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814797 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 1 EACH C1783 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814888 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 10 EACH C1783 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814805 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 2 EACH C1783 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814821 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 4 EACH C1783 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814839 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 5 EACH C1783 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814847 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 6 EACH C1783 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814854 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 7 EACH C1783 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814862 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 8 EACH C1783 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814870 IMPLANTS AQUEOUS DRAINAGE DEVICE LVL 9 EACH C1783 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812700 IMPLANTS AQUEOUS SHUNT LVL 0 EACH L8612 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812718 IMPLANTS AQUEOUS SHUNT LVL 1 EACH L8612 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812726 IMPLANTS AQUEOUS SHUNT LVL 2 EACH L8612 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812734 IMPLANTS AQUEOUS SHUNT LVL 3 EACH L8612 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812742 IMPLANTS AQUEOUS SHUNT LVL 4 EACH L8612 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812759 IMPLANTS AQUEOUS SHUNT LVL 5 EACH L8612 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812825 IMPLANTS ASTIGMATISM CORRECT IOL LVL 0 EACH V2787 $75.00 276 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812833 IMPLANTS ASTIGMATISM CORRECT IOL LVL 1 EACH V2787 $150.00 276 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812841 IMPLANTS ASTIGMATISM CORRECT IOL LVL 2 EACH V2787 $300.00 276 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812858 IMPLANTS ASTIGMATISM CORRECT IOL LVL 3 EACH V2787 $600.00 276 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812866 IMPLANTS ASTIGMATISM CORRECT IOL LVL 4 EACH V2787 "$1,200.00 " 276 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812874 IMPLANTS ASTIGMATISM CORRECT IOL LVL 5 EACH V2787 "$2,400.00 " 276 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27801109 IMPLANTS BRACE KNEE EACH L9900 $120.00 274 $84.00 $60.00 $96.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803113 IMPLANTS BREAST IMPLANT LVL 0 EACH C1789 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803121 IMPLANTS BREAST IMPLANT LVL 1 EACH C1789 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803212 IMPLANTS BREAST IMPLANT LVL 10 EACH C1789 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803139 IMPLANTS BREAST IMPLANT LVL 2 EACH C1789 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803147 IMPLANTS BREAST IMPLANT LVL 3 EACH C1789 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803154 IMPLANTS BREAST IMPLANT LVL 4 EACH C1789 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803162 IMPLANTS BREAST IMPLANT LVL 5 EACH C1789 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803170 IMPLANTS BREAST IMPLANT LVL 6 EACH C1789 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803188 IMPLANTS BREAST IMPLANT LVL 7 EACH C1789 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803196 IMPLANTS BREAST IMPLANT LVL 8 EACH C1789 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803204 IMPLANTS BREAST IMPLANT LVL 9 EACH C1789 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817816 IMPLANTS BREAST PROSTHESIS LVL 0 EACH L8600 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817824 IMPLANTS BREAST PROSTHESIS LVL 1 EACH L8600 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817915 IMPLANTS BREAST PROSTHESIS LVL 10 EACH L8600 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817832 IMPLANTS BREAST PROSTHESIS LVL 2 EACH L8600 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817840 IMPLANTS BREAST PROSTHESIS LVL 3 EACH L8600 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817857 IMPLANTS BREAST PROSTHESIS LVL 4 EACH L8600 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817865 IMPLANTS BREAST PROSTHESIS LVL 5 EACH L8600 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817873 IMPLANTS BREAST PROSTHESIS LVL 6 EACH L8600 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817881 IMPLANTS BREAST PROSTHESIS LVL 7 EACH L8600 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817899 IMPLANTS BREAST PROSTHESIS LVL 8 EACH L8600 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817907 IMPLANTS BREAST PROSTHESIS LVL 9 EACH L8600 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813195 IMPLANTS CATH ATHEREC ROTATION LVL 0 EACH C1724 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813203 IMPLANTS CATH ATHEREC ROTATION LVL 1 EACH C1724 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813294 IMPLANTS CATH ATHEREC ROTATION LVL 10 EACH C1724 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813211 IMPLANTS CATH ATHEREC ROTATION LVL 2 EACH C1724 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813229 IMPLANTS CATH ATHEREC ROTATION LVL 3 EACH C1724 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813237 IMPLANTS CATH ATHEREC ROTATION LVL 4 EACH C1724 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813245 IMPLANTS CATH ATHEREC ROTATION LVL 5 EACH C1724 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813252 IMPLANTS CATH ATHEREC ROTATION LVL 6 EACH C1724 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813260 IMPLANTS CATH ATHEREC ROTATION LVL 7 EACH C1724 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813278 IMPLANTS CATH ATHEREC ROTATION LVL 8 EACH C1724 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813286 IMPLANTS CATH ATHEREC ROTATION LVL 9 EACH C1724 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814623 IMPLANTS CATH ATHERECTOMY DIR LVL 0 EACH C1714 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812957 IMPLANTS CATH ATHERECTOMY DIR LVL 1 EACH C1714 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813187 IMPLANTS CATH ATHERECTOMY DIR LVL 10 EACH C1714 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812965 IMPLANTS CATH ATHERECTOMY DIR LVL 2 EACH C1714 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812973 IMPLANTS CATH ATHERECTOMY DIR LVL 3 EACH C1714 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812981 IMPLANTS CATH ATHERECTOMY DIR LVL 4 EACH C1714 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813138 IMPLANTS CATH ATHERECTOMY DIR LVL 5 EACH C1714 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813146 IMPLANTS CATH ATHERECTOMY DIR LVL 6 EACH C1714 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813153 IMPLANTS CATH ATHERECTOMY DIR LVL 7 EACH C1714 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813161 IMPLANTS CATH ATHERECTOMY DIR LVL 8 EACH C1714 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813179 IMPLANTS CATH ATHERECTOMY DIR LVL 9 EACH C1714 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809839 IMPLANTS CATH BAL TIS DIS N-VAS LVL 0 EACH C1727 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809847 IMPLANTS CATH BAL TIS DIS N-VAS LVL 1 EACH C1727 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809938 IMPLANTS CATH BAL TIS DIS N-VAS LVL 10 EACH C1727 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809854 IMPLANTS CATH BAL TIS DIS N-VAS LVL 2 EACH C1727 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809862 IMPLANTS CATH BAL TIS DIS N-VAS LVL 3 EACH C1727 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809870 IMPLANTS CATH BAL TIS DIS N-VAS LVL 4 EACH C1727 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809888 IMPLANTS CATH BAL TIS DIS N-VAS LVL 5 EACH C1727 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809896 IMPLANTS CATH BAL TIS DIS N-VAS LVL 6 EACH C1727 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809904 IMPLANTS CATH BAL TIS DIS N-VAS LVL 7 EACH C1727 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809912 IMPLANTS CATH BAL TIS DIS N-VAS LVL 8 EACH C1727 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809920 IMPLANTS CATH BAL TIS DIS N-VAS LVL 9 EACH C1727 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809052 IMPLANTS CATH BLN DILAT NON VASC LVL 0 EACH C1726 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809060 IMPLANTS CATH BLN DILAT NON VASC LVL 1 EACH C1726 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809151 IMPLANTS CATH BLN DILAT NON VASC LVL 10 EACH C1726 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809078 IMPLANTS CATH BLN DILAT NON VASC LVL 2 EACH C1726 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809086 IMPLANTS CATH BLN DILAT NON VASC LVL 3 EACH C1726 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809094 IMPLANTS CATH BLN DILAT NON VASC LVL 4 EACH C1726 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809102 IMPLANTS CATH BLN DILAT NON VASC LVL 5 EACH C1726 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809110 IMPLANTS CATH BLN DILAT NON VASC LVL 6 EACH C1726 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809128 IMPLANTS CATH BLN DILAT NON VASC LVL 7 EACH C1726 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809136 IMPLANTS CATH BLN DILAT NON VASC LVL 8 EACH C1726 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809144 IMPLANTS CATH BLN DILAT NON VASC LVL 9 EACH C1726 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809169 IMPLANTS CATH DIALYSIS LONGTERM LVL 0 EACH C1750 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809177 IMPLANTS CATH DIALYSIS LONGTERM LVL 1 EACH C1750 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809268 IMPLANTS CATH DIALYSIS LONGTERM LVL 10 EACH C1750 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809185 IMPLANTS CATH DIALYSIS LONGTERM LVL 2 EACH C1750 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809193 IMPLANTS CATH DIALYSIS LONGTERM LVL 3 EACH C1750 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809201 IMPLANTS CATH DIALYSIS LONGTERM LVL 4 EACH C1750 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809219 IMPLANTS CATH DIALYSIS LONGTERM LVL 5 EACH C1750 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809227 IMPLANTS CATH DIALYSIS LONGTERM LVL 6 EACH C1750 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809235 IMPLANTS CATH DIALYSIS LONGTERM LVL 7 EACH C1750 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809243 IMPLANTS CATH DIALYSIS LONGTERM LVL 8 EACH C1750 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809250 IMPLANTS CATH DIALYSIS LONGTERM LVL 9 EACH C1750 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820802 IMPLANTS CATH EXTRAVASC ABLATION LVL 6 EACH C1886 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813419 IMPLANTS CATH INTRA ECHOCARDIO LVL 0 EACH C1759 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813427 IMPLANTS CATH INTRA ECHOCARDIO LVL 1 EACH C1759 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813518 IMPLANTS CATH INTRA ECHOCARDIO LVL 10 EACH C1759 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813435 IMPLANTS CATH INTRA ECHOCARDIO LVL 2 EACH C1759 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813443 IMPLANTS CATH INTRA ECHOCARDIO LVL 3 EACH C1759 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813450 IMPLANTS CATH INTRA ECHOCARDIO LVL 4 EACH C1759 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813468 IMPLANTS CATH INTRA ECHOCARDIO LVL 5 EACH C1759 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813476 IMPLANTS CATH INTRA ECHOCARDIO LVL 6 EACH C1759 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813484 IMPLANTS CATH INTRA ECHOCARDIO LVL 7 EACH C1759 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813492 IMPLANTS CATH INTRA ECHOCARDIO LVL 8 EACH C1759 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813500 IMPLANTS CATH INTRA ECHOCARDIO LVL 9 EACH C1759 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813401 IMPLANTS CATH INTRAVAS ULTRASOUND LV 10 EACH C1753 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813302 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 0 EACH C1753 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813310 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 1 EACH C1753 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813328 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 2 EACH C1753 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813336 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 3 EACH C1753 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813344 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 4 EACH C1753 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813351 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 5 EACH C1753 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813369 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 6 EACH C1753 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813377 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 7 EACH C1753 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813385 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 8 EACH C1753 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813393 IMPLANTS CATH INTRAVAS ULTRASOUND LVL 9 EACH C1753 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810050 IMPLANTS CATH THROMB/EMBOLECT LVL 0 EACH C1757 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810068 IMPLANTS CATH THROMB/EMBOLECT LVL 1 EACH C1757 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810159 IMPLANTS CATH THROMB/EMBOLECT LVL 10 EACH C1757 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810076 IMPLANTS CATH THROMB/EMBOLECT LVL 2 EACH C1757 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810084 IMPLANTS CATH THROMB/EMBOLECT LVL 3 EACH C1757 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810092 IMPLANTS CATH THROMB/EMBOLECT LVL 4 EACH C1757 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810100 IMPLANTS CATH THROMB/EMBOLECT LVL 5 EACH C1757 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810118 IMPLANTS CATH THROMB/EMBOLECT LVL 6 EACH C1757 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810126 IMPLANTS CATH THROMB/EMBOLECT LVL 7 EACH C1757 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810134 IMPLANTS CATH THROMB/EMBOLECT LVL 8 EACH C1757 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810142 IMPLANTS CATH THROMB/EMBOLECT LVL 9 EACH C1757 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812437 IMPLANTS CATHETER ANGIO NONLASER LV 10 EACH C1725 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812338 IMPLANTS CATHETER ANGIO NONLASER LVL 0 EACH C1725 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812346 IMPLANTS CATHETER ANGIO NONLASER LVL 1 EACH C1725 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812353 IMPLANTS CATHETER ANGIO NONLASER LVL 2 EACH C1725 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812361 IMPLANTS CATHETER ANGIO NONLASER LVL 3 EACH C1725 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812379 IMPLANTS CATHETER ANGIO NONLASER LVL 4 EACH C1725 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812387 IMPLANTS CATHETER ANGIO NONLASER LVL 5 EACH C1725 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812395 IMPLANTS CATHETER ANGIO NONLASER LVL 6 EACH C1725 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812403 IMPLANTS CATHETER ANGIO NONLASER LVL 7 EACH C1725 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812411 IMPLANTS CATHETER ANGIO NONLASER LVL 8 EACH C1725 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812429 IMPLANTS CATHETER ANGIO NONLASER LVL 9 EACH C1725 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812270 IMPLANTS CATHETER DIALYSIS/PERI LVL 0 EACH C1752 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812288 IMPLANTS CATHETER DIALYSIS/PERI LVL 1 EACH C1752 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812296 IMPLANTS CATHETER DIALYSIS/PERI LVL 2 EACH C1752 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812304 IMPLANTS CATHETER DIALYSIS/PERI LVL 3 EACH C1752 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812312 IMPLANTS CATHETER DIALYSIS/PERI LVL 4 EACH C1752 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812320 IMPLANTS CATHETER DIALYSIS/PERI LVL 5 EACH C1752 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817964 IMPLANTS CATHETER URETERAL LVL 10 EACH C1758 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817923 IMPLANTS CATHETER URETERAL LVL 6 EACH C1758 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817931 IMPLANTS CATHETER URETERAL LVL 7 EACH C1758 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817949 IMPLANTS CATHETER URETERAL LVL 8 EACH C1758 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817956 IMPLANTS CATHETER URETERAL LVL 9 EACH C1758 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803337 IMPLANTS CATHETER DRAINAGE LVL 0 EACH C1729 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803345 IMPLANTS CATHETER DRAINAGE LVL 1 EACH C1729 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803436 IMPLANTS CATHETER DRAINAGE LVL 10 EACH C1729 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803352 IMPLANTS CATHETER DRAINAGE LVL 2 EACH C1729 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803360 IMPLANTS CATHETER DRAINAGE LVL 3 EACH C1729 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803378 IMPLANTS CATHETER DRAINAGE LVL 4 EACH C1729 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803386 IMPLANTS CATHETER DRAINAGE LVL 5 EACH C1729 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803394 IMPLANTS CATHETER DRAINAGE LVL 6 EACH C1729 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803402 IMPLANTS CATHETER DRAINAGE LVL 7 EACH C1729 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803410 IMPLANTS CATHETER DRAINAGE LVL 8 EACH C1729 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803428 IMPLANTS CATHETER DRAINAGE LVL 9 EACH C1729 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812486 IMPLANTS CATHETER ELECTROPHYS DX LVL 0 EACH C1730 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812494 IMPLANTS CATHETER ELECTROPHYS DX LVL 1 EACH C1730 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816008 IMPLANTS CATHETER ELECTROPHYS DX LVL 10 EACH C1730 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812502 IMPLANTS CATHETER ELECTROPHYS DX LVL 2 EACH C1730 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812510 IMPLANTS CATHETER ELECTROPHYS DX LVL 3 EACH C1730 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815943 IMPLANTS CATHETER ELECTROPHYS DX LVL 4 EACH C1730 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815950 IMPLANTS CATHETER ELECTROPHYS DX LVL 5 EACH C1730 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815968 IMPLANTS CATHETER ELECTROPHYS DX LVL 6 EACH C1730 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815976 IMPLANTS CATHETER ELECTROPHYS DX LVL 7 EACH C1730 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815984 IMPLANTS CATHETER ELECTROPHYS DX LVL 8 EACH C1730 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815992 IMPLANTS CATHETER ELECTROPHYS DX LVL 9 EACH C1730 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816016 IMPLANTS CATHETER EPS >20 ELEC DX LVL 0 EACH C1731 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816024 IMPLANTS CATHETER EPS >20 ELEC DX LVL 1 EACH C1731 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816032 IMPLANTS CATHETER EPS >20 ELEC DX LVL 2 EACH C1731 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816040 IMPLANTS CATHETER EPS >20 ELEC DX LVL 3 EACH C1731 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816057 IMPLANTS CATHETER EPS >20 ELEC DX LVL 4 EACH C1731 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816065 IMPLANTS CATHETER EPS >20 ELEC DX LVL 5 EACH C1731 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816073 IMPLANTS CATHETER EPS >20 ELEC DX LVL 6 EACH C1731 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816081 IMPLANTS CATHETER EPS >20 ELEC DX LVL 7 EACH C1731 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816099 IMPLANTS CATHETER EPS >20 ELEC DX LVL 8 EACH C1731 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816107 IMPLANTS CATHETER EPS >20 ELEC DX LVL 9 EACH C1731 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816115 IMPLANTS CATHETER EPS >20 ELEC DX LVL10 EACH C1731 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816123 IMPLANTS CATHETER EPS DX 3D LVL 0 EACH C1732 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816131 IMPLANTS CATHETER EPS DX 3D LVL 1 EACH C1732 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816222 IMPLANTS CATHETER EPS DX 3D LVL 10 EACH C1732 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816149 IMPLANTS CATHETER EPS DX 3D LVL 2 EACH C1732 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816156 IMPLANTS CATHETER EPS DX 3D LVL 3 EACH C1732 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816164 IMPLANTS CATHETER EPS DX 3D LVL 4 EACH C1732 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816172 IMPLANTS CATHETER EPS DX 3D LVL 5 EACH C1732 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816180 IMPLANTS CATHETER EPS DX 3D LVL 6 EACH C1732 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816198 IMPLANTS CATHETER EPS DX 3D LVL 7 EACH C1732 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816206 IMPLANTS CATHETER EPS DX 3D LVL 8 EACH C1732 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816214 IMPLANTS CATHETER EPS DX 3D LVL 9 EACH C1732 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816347 IMPLANTS CATHETER EPS DX COOL TIP LVL 0 EACH C2630 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816354 IMPLANTS CATHETER EPS DX COOL TIP LVL 1 EACH C2630 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816362 IMPLANTS CATHETER EPS DX COOL TIP LVL 2 EACH C2630 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816370 IMPLANTS CATHETER EPS DX COOL TIP LVL 3 EACH C2630 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816388 IMPLANTS CATHETER EPS DX COOL TIP LVL 4 EACH C2630 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816396 IMPLANTS CATHETER EPS DX COOL TIP LVL 5 EACH C2630 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816404 IMPLANTS CATHETER EPS DX COOL TIP LVL 6 EACH C2630 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816412 IMPLANTS CATHETER EPS DX COOL TIP LVL 7 EACH C2630 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816420 IMPLANTS CATHETER EPS DX COOL TIP LVL 8 EACH C2630 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816438 IMPLANTS CATHETER EPS DX COOL TIP LVL 9 EACH C2630 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816446 IMPLANTS CATHETER EPS DX COOL TIP LVL10 EACH C2630 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816230 IMPLANTS CATHETER EPS DX OTHER LVL 0 EACH C1733 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816248 IMPLANTS CATHETER EPS DX OTHER LVL 1 EACH C1733 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816339 IMPLANTS CATHETER EPS DX OTHER LVL 10 EACH C1733 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816255 IMPLANTS CATHETER EPS DX OTHER LVL 2 EACH C1733 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816263 IMPLANTS CATHETER EPS DX OTHER LVL 3 EACH C1733 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816271 IMPLANTS CATHETER EPS DX OTHER LVL 4 EACH C1733 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816289 IMPLANTS CATHETER EPS DX OTHER LVL 5 EACH C1733 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816297 IMPLANTS CATHETER EPS DX OTHER LVL 6 EACH C1733 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816305 IMPLANTS CATHETER EPS DX OTHER LVL 7 EACH C1733 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816313 IMPLANTS CATHETER EPS DX OTHER LVL 8 EACH C1733 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816321 IMPLANTS CATHETER EPS DX OTHER LVL 9 EACH C1733 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811264 IMPLANTS CATHETER GUIDING LVL 0 EACH C1887 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811272 IMPLANTS CATHETER GUIDING LVL 1 EACH C1887 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811363 IMPLANTS CATHETER GUIDING LVL 10 EACH C1887 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811280 IMPLANTS CATHETER GUIDING LVL 2 EACH C1887 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811298 IMPLANTS CATHETER GUIDING LVL 3 EACH C1887 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811306 IMPLANTS CATHETER GUIDING LVL 4 EACH C1887 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811314 IMPLANTS CATHETER GUIDING LVL 5 EACH C1887 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811322 IMPLANTS CATHETER GUIDING LVL 6 EACH C1887 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811330 IMPLANTS CATHETER GUIDING LVL 7 EACH C1887 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811348 IMPLANTS CATHETER GUIDING LVL 8 EACH C1887 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811355 IMPLANTS CATHETER GUIDING LVL 9 EACH C1887 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803444 IMPLANTS CATHETER INDWELLING LVL 0 EACH C1788 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803451 IMPLANTS CATHETER INDWELLING LVL 1 EACH C1788 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803543 IMPLANTS CATHETER INDWELLING LVL 10 EACH C1788 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803469 IMPLANTS CATHETER INDWELLING LVL 2 EACH C1788 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803477 IMPLANTS CATHETER INDWELLING LVL 3 EACH C1788 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803485 IMPLANTS CATHETER INDWELLING LVL 4 EACH C1788 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803493 IMPLANTS CATHETER INDWELLING LVL 5 EACH C1788 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803501 IMPLANTS CATHETER INDWELLING LVL 6 EACH C1788 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803519 IMPLANTS CATHETER INDWELLING LVL 7 EACH C1788 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803527 IMPLANTS CATHETER INDWELLING LVL 8 EACH C1788 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803535 IMPLANTS CATHETER INDWELLING LVL 9 EACH C1788 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803550 IMPLANTS CATHETER INFUSION LVL 0 EACH C1751 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803568 IMPLANTS CATHETER INFUSION LVL 1 EACH C1751 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803659 IMPLANTS CATHETER INFUSION LVL 10 EACH C1751 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803576 IMPLANTS CATHETER INFUSION LVL 2 EACH C1751 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803584 IMPLANTS CATHETER INFUSION LVL 3 EACH C1751 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803592 IMPLANTS CATHETER INFUSION LVL 4 EACH C1751 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803600 IMPLANTS CATHETER INFUSION LVL 5 EACH C1751 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803618 IMPLANTS CATHETER INFUSION LVL 6 EACH C1751 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803626 IMPLANTS CATHETER INFUSION LVL 7 EACH C1751 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803634 IMPLANTS CATHETER INFUSION LVL 8 EACH C1751 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27803642 IMPLANTS CATHETER INFUSION LVL 9 EACH C1751 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809946 IMPLANTS CATHETER INTRASPINAL LVL 0 EACH C1755 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809953 IMPLANTS CATHETER INTRASPINAL LVL 1 EACH C1755 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810043 IMPLANTS CATHETER INTRASPINAL LVL 10 EACH C1755 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809961 IMPLANTS CATHETER INTRASPINAL LVL 2 EACH C1755 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809979 IMPLANTS CATHETER INTRASPINAL LVL 3 EACH C1755 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809987 IMPLANTS CATHETER INTRASPINAL LVL 4 EACH C1755 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809995 IMPLANTS CATHETER INTRASPINAL LVL 5 EACH C1755 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810001 IMPLANTS CATHETER INTRASPINAL LVL 6 EACH C1755 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810019 IMPLANTS CATHETER INTRASPINAL LVL 7 EACH C1755 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810027 IMPLANTS CATHETER INTRASPINAL LVL 8 EACH C1755 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810035 IMPLANTS CATHETER INTRASPINAL LVL 9 EACH C1755 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814516 IMPLANTS CATHETER OCCLUSION LVL 0 EACH C2628 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814524 IMPLANTS CATHETER OCCLUSION LVL 1 EACH C2628 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814615 IMPLANTS CATHETER OCCLUSION LVL 10 EACH C2628 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814532 IMPLANTS CATHETER OCCLUSION LVL 2 EACH C2628 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814540 IMPLANTS CATHETER OCCLUSION LVL 3 EACH C2628 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814557 IMPLANTS CATHETER OCCLUSION LVL 4 EACH C2628 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814565 IMPLANTS CATHETER OCCLUSION LVL 5 EACH C2628 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814573 IMPLANTS CATHETER OCCLUSION LVL 6 EACH C2628 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814581 IMPLANTS CATHETER OCCLUSION LVL 7 EACH C2628 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814599 IMPLANTS CATHETER OCCLUSION LVL 8 EACH C2628 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814607 IMPLANTS CATHETER OCCLUSION LVL 9 EACH C2628 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809490 IMPLANTS CATHETER SUPRAPUBIC LVL 0 EACH C2627 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809508 IMPLANTS CATHETER SUPRAPUBIC LVL 1 EACH C2627 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809599 IMPLANTS CATHETER SUPRAPUBIC LVL 10 EACH C2627 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809516 IMPLANTS CATHETER SUPRAPUBIC LVL 2 EACH C2627 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809524 IMPLANTS CATHETER SUPRAPUBIC LVL 3 EACH C2627 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809532 IMPLANTS CATHETER SUPRAPUBIC LVL 4 EACH C2627 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809540 IMPLANTS CATHETER SUPRAPUBIC LVL 5 EACH C2627 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809557 IMPLANTS CATHETER SUPRAPUBIC LVL 6 EACH C2627 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809565 IMPLANTS CATHETER SUPRAPUBIC LVL 7 EACH C2627 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809573 IMPLANTS CATHETER SUPRAPUBIC LVL 8 EACH C2627 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809581 IMPLANTS CATHETER SUPRAPUBIC LVL 9 EACH C2627 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816578 IMPLANTS "CATHETER, OCCLUSION LVL 0 " EACH C2628 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816586 IMPLANTS "CATHETER, OCCLUSION LVL 1 " EACH C2628 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816677 IMPLANTS "CATHETER, OCCLUSION LVL 10 " EACH C2628 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816594 IMPLANTS "CATHETER, OCCLUSION LVL 2 " EACH C2628 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816602 IMPLANTS "CATHETER, OCCLUSION LVL 3 " EACH C2628 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816610 IMPLANTS "CATHETER, OCCLUSION LVL 4 " EACH C2628 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816628 IMPLANTS "CATHETER, OCCLUSION LVL 5 " EACH C2628 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816636 IMPLANTS "CATHETER, OCCLUSION LVL 6 " EACH C2628 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816644 IMPLANTS "CATHETER, OCCLUSION LVL 7 " EACH C2628 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816651 IMPLANTS "CATHETER, OCCLUSION LVL 8 " EACH C2628 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816669 IMPLANTS "CATHETER, OCCLUSION LVL 9 " EACH C2628 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810167 IMPLANTS CLOSURE DEV VASC LVL 0 EACH C1760 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810175 IMPLANTS CLOSURE DEV VASC LVL 1 EACH C1760 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810266 IMPLANTS CLOSURE DEV VASC LVL 10 EACH C1760 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810183 IMPLANTS CLOSURE DEV VASC LVL 2 EACH C1760 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810191 IMPLANTS CLOSURE DEV VASC LVL 3 EACH C1760 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810209 IMPLANTS CLOSURE DEV VASC LVL 4 EACH C1760 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810217 IMPLANTS CLOSURE DEV VASC LVL 5 EACH C1760 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810225 IMPLANTS CLOSURE DEV VASC LVL 6 EACH C1760 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810233 IMPLANTS CLOSURE DEV VASC LVL 7 EACH C1760 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810241 IMPLANTS CLOSURE DEV VASC LVL 8 EACH C1760 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810258 IMPLANTS CLOSURE DEV VASC LVL 9 EACH C1760 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816792 IMPLANTS COLLAGEN NERVE CUFF LVL 0 EACH C9355 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816800 IMPLANTS COLLAGEN NERVE CUFF LVL 1 EACH C9355 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816891 IMPLANTS COLLAGEN NERVE CUFF LVL 10 EACH C9355 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816818 IMPLANTS COLLAGEN NERVE CUFF LVL 2 EACH C9355 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816826 IMPLANTS COLLAGEN NERVE CUFF LVL 3 EACH C9355 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816834 IMPLANTS COLLAGEN NERVE CUFF LVL 4 EACH C9355 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816842 IMPLANTS COLLAGEN NERVE CUFF LVL 5 EACH C9355 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816859 IMPLANTS COLLAGEN NERVE CUFF LVL 6 EACH C9355 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816867 IMPLANTS COLLAGEN NERVE CUFF LVL 7 EACH C9355 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816875 IMPLANTS COLLAGEN NERVE CUFF LVL 8 EACH C9355 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816883 IMPLANTS COLLAGEN NERVE CUFF LVL 9 EACH C9355 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814771 IMPLANTS COLLAGEN NERVE WRAP .5 CM L-10 EACH C9360 "$26,000.00 " 636 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814672 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-0 EACH C9360 $75.00 636 $52.50 $37.50 $60.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814680 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-1 EACH C9360 $150.00 636 $105.00 $75.00 $120.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814698 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-2 EACH C9360 $300.00 636 $210.00 $150.00 $240.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814706 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-3 EACH C9360 $600.00 636 $420.00 $300.00 $480.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814714 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-4 EACH C9360 "$1,200.00 " 636 $840.00 $600.00 $960.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814722 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-5 EACH C9360 "$2,400.00 " 636 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814730 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-6 EACH C9360 "$5,000.00 " 636 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814748 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-7 EACH C9360 "$9,400.00 " 636 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814755 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-8 EACH C9360 "$15,000.00 " 636 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27814763 IMPLANTS COLLAGEN NERVE WRAP 0.5 CM L-9 EACH C9360 "$20,000.00 " 636 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27801224 IMPLANTS COLLAR CERV SOFT EACH L0120 $26.89 274 $18.82 $13.45 $21.51 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810274 IMPLANTS CONN TISS HUMAN LVL 0 EACH C1762 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810282 IMPLANTS CONN TISS HUMAN LVL 1 EACH C1762 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810373 IMPLANTS CONN TISS HUMAN LVL 10 EACH C1762 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810290 IMPLANTS CONN TISS HUMAN LVL 2 EACH C1762 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810308 IMPLANTS CONN TISS HUMAN LVL 3 EACH C1762 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810316 IMPLANTS CONN TISS HUMAN LVL 4 EACH C1762 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810324 IMPLANTS CONN TISS HUMAN LVL 5 EACH C1762 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810332 IMPLANTS CONN TISS HUMAN LVL 6 EACH C1762 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810340 IMPLANTS CONN TISS HUMAN LVL 7 EACH C1762 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810357 IMPLANTS CONN TISS HUMAN LVL 8 EACH C1762 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810365 IMPLANTS CONN TISS HUMAN LVL 9 EACH C1762 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810381 IMPLANTS CONN TISS NON-HUMAN LVL 0 EACH C1763 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810399 IMPLANTS CONN TISS NON-HUMAN LVL 1 EACH C1763 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810480 IMPLANTS CONN TISS NON-HUMAN LVL 10 EACH C1763 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810407 IMPLANTS CONN TISS NON-HUMAN LVL 2 EACH C1763 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810415 IMPLANTS CONN TISS NON-HUMAN LVL 3 EACH C1763 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810423 IMPLANTS CONN TISS NON-HUMAN LVL 4 EACH C1763 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810431 IMPLANTS CONN TISS NON-HUMAN LVL 5 EACH C1763 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810449 IMPLANTS CONN TISS NON-HUMAN LVL 6 EACH C1763 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810456 IMPLANTS CONN TISS NON-HUMAN LVL 7 EACH C1763 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810464 IMPLANTS CONN TISS NON-HUMAN LVL 8 EACH C1763 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810472 IMPLANTS CONN TISS NON-HUMAN LVL 9 EACH C1763 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819747 IMPLANTS CONTACT LAYER < 16 LVL 0 EACH A6206 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819754 IMPLANTS CONTACT LAYER < 16 LVL 1 EACH A6206 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819762 IMPLANTS CONTACT LAYER < 16 LVL 2 EACH A6206 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819770 IMPLANTS CONTACT LAYER < 16 LVL 3 EACH A6206 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819788 IMPLANTS CONTACT LAYER < 16 LVL 4 EACH A6206 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819796 IMPLANTS CONTACT LAYER < 16 LVL 5 EACH A6206 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819804 IMPLANTS CONTACT LAYER 16-48 LVL 0 EACH A6207 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819812 IMPLANTS CONTACT LAYER 16-48 LVL 1 EACH A6207 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819820 IMPLANTS CONTACT LAYER 16-48 LVL 2 EACH A6207 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819838 IMPLANTS CONTACT LAYER 16-48 LVL 3 EACH A6207 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819846 IMPLANTS CONTACT LAYER 16-48 LVL 4 EACH A6207 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819853 IMPLANTS CONTACT LAYER 16-48 LVL 5 EACH A6207 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819861 IMPLANTS CONTACT LAYER 48+ LVL 0 EACH A6208 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819879 IMPLANTS CONTACT LAYER 48+ LVL 1 EACH A6208 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819887 IMPLANTS CONTACT LAYER 48+ LVL 2 EACH A6208 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819895 IMPLANTS CONTACT LAYER 48+ LVL 3 EACH A6208 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819903 IMPLANTS CONTACT LAYER 48+ LVL 4 EACH A6208 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819911 IMPLANTS CONTACT LAYER 48+ LVL 5 EACH A6208 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820380 IMPLANTS DERMACEL PER SQ CM LVL 0 EACH Q4122 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820398 IMPLANTS DERMACEL PER SQ CM LVL 1 EACH Q4122 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820489 IMPLANTS DERMACEL PER SQ CM LVL 10 EACH Q4122 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820406 IMPLANTS DERMACEL PER SQ CM LVL 2 EACH Q4122 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820414 IMPLANTS DERMACEL PER SQ CM LVL 3 EACH Q4122 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820422 IMPLANTS DERMACEL PER SQ CM LVL 4 EACH Q4122 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820430 IMPLANTS DERMACEL PER SQ CM LVL 5 EACH Q4122 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820448 IMPLANTS DERMACEL PER SQ CM LVL 6 EACH Q4122 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820455 IMPLANTS DERMACEL PER SQ CM LVL 7 EACH Q4122 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820463 IMPLANTS DERMACEL PER SQ CM LVL 8 EACH Q4122 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820471 IMPLANTS DERMACEL PER SQ CM LVL 9 EACH Q4122 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819564 IMPLANTS DRESS W/ADH BORDER < 16 LVL 0 EACH A6203 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819572 IMPLANTS DRESS W/ADH BORDER < 16 LVL 1 EACH A6203 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819580 IMPLANTS DRESS W/ADH BORDER < 16 LVL 2 EACH A6203 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819598 IMPLANTS DRESS W/ADH BORDER < 16 LVL 3 EACH A6203 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819606 IMPLANTS DRESS W/ADH BORDER < 16 LVL 4 EACH A6203 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges Non Payable 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819614 IMPLANTS DRESS W/ADH BORDER < 16 LVL 5 EACH A6203 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges Non Payable 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819622 IMPLANTS DRESS W/ADH BORDER 16-48 LVL 0 EACH A6204 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819630 IMPLANTS DRESS W/ADH BORDER 16-48 LVL 1 EACH A6204 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819648 IMPLANTS DRESS W/ADH BORDER 16-48 LVL 2 EACH A6204 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819655 IMPLANTS DRESS W/ADH BORDER 16-48 LVL 3 EACH A6204 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819663 IMPLANTS DRESS W/ADH BORDER 16-48 LVL 4 EACH A6204 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819671 IMPLANTS DRESS W/ADH BORDER 16-48 LVL 5 EACH A6204 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819689 IMPLANTS DRESS W/ADH BORDER 48+ LVL 0 EACH A6205 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819697 IMPLANTS DRESS W/ADH BORDER 48+ LVL 1 EACH A6205 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819705 IMPLANTS DRESS W/ADH BORDER 48+ LVL 2 EACH A6205 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819713 IMPLANTS DRESS W/ADH BORDER 48+ LVL 3 EACH A6205 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819721 IMPLANTS DRESS W/ADH BORDER 48+ LVL 4 EACH A6205 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819739 IMPLANTS DRESS W/ADH BORDER 48+ LVL 5 EACH A6205 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27801299 IMPLANTS DRSG GEL SHEET SILICONE EACH $388.69 272 $272.08 $194.35 $310.95 65% 80% 50% 50% 65% 65% 65% 27815687 IMPLANTS ELIPSE DC DF4 ICD SYS MERLIN EACH C1785 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815661 IMPLANTS ELIPSE DC DF4 ICD SYSTEM EACH C1785 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811256 IMPLANTS EMBOLIZATION PROTECT SYS L 10 EACH C1884 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811157 IMPLANTS EMBOLIZATION PROTECT SYS LVL 0 EACH C1884 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811165 IMPLANTS EMBOLIZATION PROTECT SYS LVL 1 EACH C1884 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811173 IMPLANTS EMBOLIZATION PROTECT SYS LVL 2 EACH C1884 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811181 IMPLANTS EMBOLIZATION PROTECT SYS LVL 3 EACH C1884 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811199 IMPLANTS EMBOLIZATION PROTECT SYS LVL 4 EACH C1884 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811207 IMPLANTS EMBOLIZATION PROTECT SYS LVL 5 EACH C1884 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811215 IMPLANTS EMBOLIZATION PROTECT SYS LVL 6 EACH C1884 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811223 IMPLANTS EMBOLIZATION PROTECT SYS LVL 7 EACH C1884 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811231 IMPLANTS EMBOLIZATION PROTECT SYS LVL 8 EACH C1884 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811249 IMPLANTS EMBOLIZATION PROTECT SYS LVL 9 EACH C1884 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815000 IMPLANTS EPS INTRODUCER/SHEATH LVL 0 EACH C1766 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815018 IMPLANTS EPS INTRODUCER/SHEATH LVL 1 EACH C1766 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815240 IMPLANTS EPS INTRODUCER/SHEATH LVL 10 EACH C1766 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815166 IMPLANTS EPS INTRODUCER/SHEATH LVL 2 EACH C1766 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815174 IMPLANTS EPS INTRODUCER/SHEATH LVL 3 EACH C1766 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815182 IMPLANTS EPS INTRODUCER/SHEATH LVL 4 EACH C1766 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815190 IMPLANTS EPS INTRODUCER/SHEATH LVL 5 EACH C1766 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815208 IMPLANTS EPS INTRODUCER/SHEATH LVL 6 EACH C1766 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815216 IMPLANTS EPS INTRODUCER/SHEATH LVL 7 EACH C1766 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815224 IMPLANTS EPS INTRODUCER/SHEATH LVL 8 EACH C1766 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815232 IMPLANTS EPS INTRODUCER/SHEATH LVL 9 EACH C1766 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813625 IMPLANTS EVENT RECORDER CARDIAC LV 10 EACH C1764 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812528 IMPLANTS EVENT RECORDER CARDIAC LVL 0 EACH C1764 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812536 IMPLANTS EVENT RECORDER CARDIAC LVL 1 EACH C1764 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814938 IMPLANTS EVENT RECORDER CARDIAC LVL 10 EACH C1764 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812544 IMPLANTS EVENT RECORDER CARDIAC LVL 2 EACH C1764 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812551 IMPLANTS EVENT RECORDER CARDIAC LVL 3 EACH C1764 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812569 IMPLANTS EVENT RECORDER CARDIAC LVL 4 EACH C1764 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812577 IMPLANTS EVENT RECORDER CARDIAC LVL 5 EACH C1764 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813583 IMPLANTS EVENT RECORDER CARDIAC LVL 6 EACH C1764 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814896 IMPLANTS EVENT RECORDER CARDIAC LVL 6 EACH C1764 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813591 IMPLANTS EVENT RECORDER CARDIAC LVL 7 EACH C1764 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814904 IMPLANTS EVENT RECORDER CARDIAC LVL 7 EACH C1764 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813609 IMPLANTS EVENT RECORDER CARDIAC LVL 8 EACH C1764 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814912 IMPLANTS EVENT RECORDER CARDIAC LVL 8 EACH C1764 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813617 IMPLANTS EVENT RECORDER CARDIAC LVL 9 EACH C1764 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814920 IMPLANTS EVENT RECORDER CARDIAC LVL 9 EACH C1764 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815646 IMPLANTS FORTIFY DC DF1 ICD SYS MERLIN EACH C1785 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815638 IMPLANTS FORTIFY DC DF1 ICD SYSTEM EACH C1785 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815703 IMPLANTS FORTIFY DC DF4 ICD SYS MERLIN EACH C1785 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815695 IMPLANTS FORTIFY DC DF4 ICD SYSTEM EACH C1785 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815679 IMPLANTS FORTIFY SC DF4 ICD SYS MERLIN EACH C1785 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815653 IMPLANTS FORTIFY SC DF4 ICD SYSTEM EACH C1785 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816453 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL0 EACH B4087 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816461 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL1 EACH B4087 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816552 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL10 EACH B4087 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816479 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL2 EACH B4087 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816487 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL3 EACH B4087 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816495 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL4 EACH B4087 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816503 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL5 EACH B4087 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816511 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL6 EACH B4087 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816529 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL7 EACH B4087 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816537 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL8 EACH B4087 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816545 IMPLANTS GASTRO/JEJUNOSTOMY TUBE LVL9 EACH B4087 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810597 IMPLANTS GENERATOR-NEURO NON-RECH L10 EACH C1767 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810498 IMPLANTS GENERATOR-NEURO NON-RECH LVL 0 EACH C1767 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810506 IMPLANTS GENERATOR-NEURO NON-RECH LVL 1 EACH C1767 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810514 IMPLANTS GENERATOR-NEURO NON-RECH LVL 2 EACH C1767 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810522 IMPLANTS GENERATOR-NEURO NON-RECH LVL 3 EACH C1767 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810530 IMPLANTS GENERATOR-NEURO NON-RECH LVL 4 EACH C1767 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810548 IMPLANTS GENERATOR-NEURO NON-RECH LVL 5 EACH C1767 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810555 IMPLANTS GENERATOR-NEURO NON-RECH LVL 6 EACH C1767 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810563 IMPLANTS GENERATOR-NEURO NON-RECH LVL 7 EACH C1767 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810571 IMPLANTS GENERATOR-NEURO NON-RECH LVL 8 EACH C1767 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810589 IMPLANTS GENERATOR-NEURO NON-RECH LVL 9 EACH C1767 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804871 IMPLANTS GRAFT NERVE NEUROMEND LVL 0 EACH C9361 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804889 IMPLANTS GRAFT NERVE NEUROMEND LVL 1 EACH C9361 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804970 IMPLANTS GRAFT NERVE NEUROMEND LVL 10 EACH C9361 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804897 IMPLANTS GRAFT NERVE NEUROMEND LVL 2 EACH C9361 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804905 IMPLANTS GRAFT NERVE NEUROMEND LVL 3 EACH C9361 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804913 IMPLANTS GRAFT NERVE NEUROMEND LVL 4 EACH C9361 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804921 IMPLANTS GRAFT NERVE NEUROMEND LVL 5 EACH C9361 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804939 IMPLANTS GRAFT NERVE NEUROMEND LVL 6 EACH C9361 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804947 IMPLANTS GRAFT NERVE NEUROMEND LVL 7 EACH C9361 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804954 IMPLANTS GRAFT NERVE NEUROMEND LVL 8 EACH C9361 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27804962 IMPLANTS GRAFT NERVE NEUROMEND LVL 9 EACH C9361 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814664 IMPLANTS GRAFT SKN BRN CRPRS PER SQ CM EACH C1762 $6.00 278 $4.20 $3.00 $4.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805092 IMPLANTS GRAFT TISSUE PERMACOL LVL 0 EACH C9364 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805100 IMPLANTS GRAFT TISSUE PERMACOL LVL 1 EACH C9364 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805191 IMPLANTS GRAFT TISSUE PERMACOL LVL 10 EACH C9364 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805118 IMPLANTS GRAFT TISSUE PERMACOL LVL 2 EACH C9364 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805126 IMPLANTS GRAFT TISSUE PERMACOL LVL 3 EACH C9364 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805134 IMPLANTS GRAFT TISSUE PERMACOL LVL 4 EACH C9364 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805142 IMPLANTS GRAFT TISSUE PERMACOL LVL 5 EACH C9364 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805159 IMPLANTS GRAFT TISSUE PERMACOL LVL 6 EACH C9364 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805167 IMPLANTS GRAFT TISSUE PERMACOL LVL 7 EACH C9364 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805175 IMPLANTS GRAFT TISSUE PERMACOL LVL 8 EACH C9364 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805183 IMPLANTS GRAFT TISSUE PERMACOL LVL 9 EACH C9364 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805209 IMPLANTS GRAFT TISSUE SURGIMEND LVL 0 EACH C9358 $75.00 636 $52.50 $37.50 $60.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805217 IMPLANTS GRAFT TISSUE SURGIMEND LVL 1 EACH C9358 $150.00 636 $105.00 $75.00 $120.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805308 IMPLANTS GRAFT TISSUE SURGIMEND LVL 10 EACH C9358 "$26,000.00 " 636 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805225 IMPLANTS GRAFT TISSUE SURGIMEND LVL 2 EACH C9358 $300.00 636 $210.00 $150.00 $240.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805233 IMPLANTS GRAFT TISSUE SURGIMEND LVL 3 EACH C9358 $600.00 636 $420.00 $300.00 $480.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805241 IMPLANTS GRAFT TISSUE SURGIMEND LVL 4 EACH C9358 "$1,200.00 " 636 $840.00 $600.00 $960.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805258 IMPLANTS GRAFT TISSUE SURGIMEND LVL 5 EACH C9358 "$2,400.00 " 636 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805266 IMPLANTS GRAFT TISSUE SURGIMEND LVL 6 EACH C9358 "$5,000.00 " 636 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805274 IMPLANTS GRAFT TISSUE SURGIMEND LVL 7 EACH C9358 "$9,400.00 " 636 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805282 IMPLANTS GRAFT TISSUE SURGIMEND LVL 8 EACH C9358 "$15,000.00 " 636 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805290 IMPLANTS GRAFT TISSUE SURGIMEND LVL 9 EACH C9358 "$20,000.00 " 636 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27805316 IMPLANTS GRAFT VASCULAR LVL 0 EACH C1768 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805324 IMPLANTS GRAFT VASCULAR LVL 1 EACH C1768 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805415 IMPLANTS GRAFT VASCULAR LVL 10 EACH C1768 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805332 IMPLANTS GRAFT VASCULAR LVL 2 EACH C1768 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805340 IMPLANTS GRAFT VASCULAR LVL 3 EACH C1768 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805357 IMPLANTS GRAFT VASCULAR LVL 4 EACH C1768 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805365 IMPLANTS GRAFT VASCULAR LVL 5 EACH C1768 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805373 IMPLANTS GRAFT VASCULAR LVL 6 EACH C1768 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805381 IMPLANTS GRAFT VASCULAR LVL 7 EACH C1768 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805399 IMPLANTS GRAFT VASCULAR LVL 8 EACH C1768 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805407 IMPLANTS GRAFT VASCULAR LVL 9 EACH C1768 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809276 IMPLANTS GUIDEWIRE LVL 0 EACH C1769 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809284 IMPLANTS GUIDEWIRE LVL 1 EACH C1769 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809375 IMPLANTS GUIDEWIRE LVL 10 EACH C1769 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809292 IMPLANTS GUIDEWIRE LVL 2 EACH C1769 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809300 IMPLANTS GUIDEWIRE LVL 3 EACH C1769 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809318 IMPLANTS GUIDEWIRE LVL 4 EACH C1769 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809326 IMPLANTS GUIDEWIRE LVL 5 EACH C1769 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809334 IMPLANTS GUIDEWIRE LVL 6 EACH C1769 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809342 IMPLANTS GUIDEWIRE LVL 7 EACH C1769 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809359 IMPLANTS GUIDEWIRE LVL 8 EACH C1769 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809367 IMPLANTS GUIDEWIRE LVL 9 EACH C1769 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27801364 IMPLANTS HYDROGEN PEROXIDE 3% 16OZ EACH $3.33 270 $2.33 $1.67 $2.66 65% 80% 50% 50% 65% 65% 65% 27812882 IMPLANTS I STENT LVL 0 EACH L8699 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812890 IMPLANTS I STENT LVL 1 EACH L8699 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812908 IMPLANTS I STENT LVL 2 EACH L8699 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812916 IMPLANTS I STENT LVL 3 EACH L8699 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812924 IMPLANTS I STENT LVL 4 EACH L8699 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812932 IMPLANTS I STENT LVL 5 EACH L8699 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812940 IMPLANTS I STENT LVL 6 EACH L8699 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819937 IMPLANTS "IBALANCE TKA, LIG BAL SYST SET" EACH C1776 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815307 IMPLANTS ICD DUAL CHAMBER LVL 0 EACH C1721 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815315 IMPLANTS ICD DUAL CHAMBER LVL 1 EACH C1721 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815406 IMPLANTS ICD DUAL CHAMBER LVL 10 EACH C1721 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815323 IMPLANTS ICD DUAL CHAMBER LVL 2 EACH C1721 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815331 IMPLANTS ICD DUAL CHAMBER LVL 3 EACH C1721 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815349 IMPLANTS ICD DUAL CHAMBER LVL 4 EACH C1721 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815356 IMPLANTS ICD DUAL CHAMBER LVL 5 EACH C1721 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815364 IMPLANTS ICD DUAL CHAMBER LVL 6 EACH C1721 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815372 IMPLANTS ICD DUAL CHAMBER LVL 7 EACH C1721 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815380 IMPLANTS ICD DUAL CHAMBER LVL 8 EACH C1721 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815398 IMPLANTS ICD DUAL CHAMBER LVL 9 EACH C1721 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815414 IMPLANTS ICD SINGLE CHAMBER LVL 0 EACH C1722 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815422 IMPLANTS ICD SINGLE CHAMBER LVL 1 EACH C1722 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815513 IMPLANTS ICD SINGLE CHAMBER LVL 10 EACH C1722 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815430 IMPLANTS ICD SINGLE CHAMBER LVL 2 EACH C1722 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815448 IMPLANTS ICD SINGLE CHAMBER LVL 3 EACH C1722 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815455 IMPLANTS ICD SINGLE CHAMBER LVL 4 EACH C1722 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815463 IMPLANTS ICD SINGLE CHAMBER LVL 5 EACH C1722 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815471 IMPLANTS ICD SINGLE CHAMBER LVL 6 EACH C1722 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815489 IMPLANTS ICD SINGLE CHAMBER LVL 7 EACH C1722 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815497 IMPLANTS ICD SINGLE CHAMBER LVL 8 EACH C1722 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815505 IMPLANTS ICD SINGLE CHAMBER LVL 9 EACH C1722 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27801372 IMPLANTS IMMOBILIZER SHOULDER EACH $119.25 272 $83.48 $59.63 $95.40 65% 80% 50% 50% 65% 65% 65% 27817709 IMPLANTS IMPLANT/DEVICE NOS LVL 0 EACH C1889 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817717 IMPLANTS IMPLANT/DEVICE NOS LVL 1 EACH C1889 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817808 IMPLANTS IMPLANT/DEVICE NOS LVL 10 EACH C1889 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817725 IMPLANTS IMPLANT/DEVICE NOS LVL 2 EACH C1889 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817733 IMPLANTS IMPLANT/DEVICE NOS LVL 3 EACH C1889 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817741 IMPLANTS IMPLANT/DEVICE NOS LVL 4 EACH C1889 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817758 IMPLANTS IMPLANT/DEVICE NOS LVL 5 EACH C1889 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817766 IMPLANTS IMPLANT/DEVICE NOS LVL 6 EACH C1889 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817774 IMPLANTS IMPLANT/DEVICE NOS LVL 7 EACH C1889 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817782 IMPLANTS IMPLANT/DEVICE NOS LVL 8 EACH C1889 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817790 IMPLANTS IMPLANT/DEVICE NOS LVL 9 EACH C1889 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814946 IMPLANTS IMPLANTABLE ACCESS CATH LVL 0 EACH A4300 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges Non Payable 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814953 IMPLANTS IMPLANTABLE ACCESS CATH LVL 1 EACH A4300 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges Non Payable 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814961 IMPLANTS IMPLANTABLE ACCESS CATH LVL 2 EACH A4300 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges Non Payable 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814979 IMPLANTS IMPLANTABLE ACCESS CATH LVL 3 EACH A4300 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges Non Payable 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814987 IMPLANTS IMPLANTABLE ACCESS CATH LVL 4 EACH A4300 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges Non Payable 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814995 IMPLANTS IMPLANTABLE ACCESS CATH LVL 5 EACH A4300 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges Non Payable 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812585 IMPLANTS INFUS PUMP PROGRAM. LVL 0 EACH C1772 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812593 IMPLANTS INFUS PUMP PROGRAM. LVL 1 EACH C1772 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812601 IMPLANTS INFUS PUMP PROGRAM. LVL 2 EACH C1772 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812619 IMPLANTS INFUS PUMP PROGRAM. LVL 3 EACH C1772 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812627 IMPLANTS INFUS PUMP PROGRAM. LVL 4 EACH C1772 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812635 IMPLANTS INFUS PUMP PROGRAM. LVL 5 EACH C1772 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817485 IMPLANTS INTEGRA BMWD LVL 0 EACH Q4104 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817493 IMPLANTS INTEGRA BMWD LVL 1 EACH Q4104 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817584 IMPLANTS INTEGRA BMWD LVL 10 EACH Q4104 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817501 IMPLANTS INTEGRA BMWD LVL 2 EACH Q4104 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817519 IMPLANTS INTEGRA BMWD LVL 3 EACH Q4104 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817527 IMPLANTS INTEGRA BMWD LVL 4 EACH Q4104 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817535 IMPLANTS INTEGRA BMWD LVL 5 EACH Q4104 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817543 IMPLANTS INTEGRA BMWD LVL 6 EACH Q4104 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817550 IMPLANTS INTEGRA BMWD LVL 7 EACH Q4104 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817568 IMPLANTS INTEGRA BMWD LVL 8 EACH Q4104 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817576 IMPLANTS INTEGRA BMWD LVL 9 EACH Q4104 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817592 IMPLANTS INTEGRA DRT LVL 0 EACH Q4105 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817600 IMPLANTS INTEGRA DRT LVL 1 EACH Q4105 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817691 IMPLANTS INTEGRA DRT LVL 10 EACH Q4105 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817618 IMPLANTS INTEGRA DRT LVL 2 EACH Q4105 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817626 IMPLANTS INTEGRA DRT LVL 3 EACH Q4105 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817634 IMPLANTS INTEGRA DRT LVL 4 EACH Q4105 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817642 IMPLANTS INTEGRA DRT LVL 5 EACH Q4105 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817659 IMPLANTS INTEGRA DRT LVL 6 EACH Q4105 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817667 IMPLANTS INTEGRA DRT LVL 7 EACH Q4105 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817675 IMPLANTS INTEGRA DRT LVL 8 EACH Q4105 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817683 IMPLANTS INTEGRA DRT LVL 9 EACH Q4105 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820513 IMPLANTS INTERPHALANG JT SPACER LVL 0 EACH L8658 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820521 IMPLANTS INTERPHALANG JT SPACER LVL 1 EACH L8658 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820612 IMPLANTS INTERPHALANG JT SPACER LVL 10 EACH L8658 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820539 IMPLANTS INTERPHALANG JT SPACER LVL 2 EACH L8658 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820547 IMPLANTS INTERPHALANG JT SPACER LVL 3 EACH L8658 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820554 IMPLANTS INTERPHALANG JT SPACER LVL 4 EACH L8658 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820562 IMPLANTS INTERPHALANG JT SPACER LVL 5 EACH L8658 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820570 IMPLANTS INTERPHALANG JT SPACER LVL 6 EACH L8658 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820588 IMPLANTS INTERPHALANG JT SPACER LVL 7 EACH L8658 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820596 IMPLANTS INTERPHALANG JT SPACER LVL 8 EACH L8658 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820604 IMPLANTS INTERPHALANG JT SPACER LVL 9 EACH L8658 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820273 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 0 EACH C1821 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820281 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 1 EACH C1821 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820299 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 2 EACH C1821 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820307 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 3 EACH C1821 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820315 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 4 EACH C1821 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820323 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 5 EACH C1821 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820331 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 6 EACH C1821 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820349 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 7 EACH C1821 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820356 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 8 EACH C1821 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820364 IMPLANTS INTERSPINOUS DISTRCT DEV LVL 9 EACH C1821 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820372 IMPLANTS INTERSPINOUS DISTRCT DEV LVL10 EACH C1821 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812213 IMPLANTS INTRO/SHEATH GUIDING LVL 0 EACH C1892 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812221 IMPLANTS INTRO/SHEATH GUIDING LVL 1 EACH C1892 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812239 IMPLANTS INTRO/SHEATH GUIDING LVL 2 EACH C1892 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812247 IMPLANTS INTRO/SHEATH GUIDING LVL 3 EACH C1892 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812254 IMPLANTS INTRO/SHEATH GUIDING LVL 4 EACH C1892 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812262 IMPLANTS INTRO/SHEATH GUIDING LVL 5 EACH C1892 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812155 IMPLANTS INTRODUCER/SHEATH LVL 0 EACH C1894 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812163 IMPLANTS INTRODUCER/SHEATH LVL 1 EACH C1894 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815299 IMPLANTS INTRODUCER/SHEATH LVL 10 EACH C1894 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812171 IMPLANTS INTRODUCER/SHEATH LVL 2 EACH C1894 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812189 IMPLANTS INTRODUCER/SHEATH LVL 3 EACH C1894 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812197 IMPLANTS INTRODUCER/SHEATH LVL 4 EACH C1894 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812205 IMPLANTS INTRODUCER/SHEATH LVL 5 EACH C1894 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815257 IMPLANTS INTRODUCER/SHEATH LVL 6 EACH C1894 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815265 IMPLANTS INTRODUCER/SHEATH LVL 7 EACH C1894 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815273 IMPLANTS INTRODUCER/SHEATH LVL 8 EACH C1894 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815281 IMPLANTS INTRODUCER/SHEATH LVL 9 EACH C1894 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815935 IMPLANTS IS4/DF4 PSA CONNECTOR SLEEVE EACH C2621 "$37,500.00 " 275 "$26,250.00 " "$18,750.00 " "$30,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805423 IMPLANTS JOINT COMPONENT LVL 0 EACH C1776 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805431 IMPLANTS JOINT COMPONENT LVL 1 EACH C1776 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805522 IMPLANTS JOINT COMPONENT LVL 10 EACH C1776 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805449 IMPLANTS JOINT COMPONENT LVL 2 EACH C1776 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805456 IMPLANTS JOINT COMPONENT LVL 3 EACH C1776 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805464 IMPLANTS JOINT COMPONENT LVL 4 EACH C1776 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805472 IMPLANTS JOINT COMPONENT LVL 5 EACH C1776 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805480 IMPLANTS JOINT COMPONENT LVL 6 EACH C1776 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805498 IMPLANTS JOINT COMPONENT LVL 7 EACH C1776 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805506 IMPLANTS JOINT COMPONENT LVL 8 EACH C1776 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805514 IMPLANTS JOINT COMPONENT LVL 9 EACH C1776 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815778 IMPLANTS LEAD CARD DEFIB DUAL LVL 0 EACH C1895 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815786 IMPLANTS LEAD CARD DEFIB DUAL LVL 1 EACH C1895 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815877 IMPLANTS LEAD CARD DEFIB DUAL LVL 10 EACH C1895 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815794 IMPLANTS LEAD CARD DEFIB DUAL LVL 2 EACH C1895 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815802 IMPLANTS LEAD CARD DEFIB DUAL LVL 3 EACH C1895 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815810 IMPLANTS LEAD CARD DEFIB DUAL LVL 4 EACH C1895 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815828 IMPLANTS LEAD CARD DEFIB DUAL LVL 5 EACH C1895 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815836 IMPLANTS LEAD CARD DEFIB DUAL LVL 6 EACH C1895 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815844 IMPLANTS LEAD CARD DEFIB DUAL LVL 7 EACH C1895 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815851 IMPLANTS LEAD CARD DEFIB DUAL LVL 8 EACH C1895 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815869 IMPLANTS LEAD CARD DEFIB DUAL LVL 9 EACH C1895 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815521 IMPLANTS LEAD CARD DEFIB SINGLE LVL 0 EACH C1777 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815539 IMPLANTS LEAD CARD DEFIB SINGLE LVL 1 EACH C1777 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815620 IMPLANTS LEAD CARD DEFIB SINGLE LVL 10 EACH C1777 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815547 IMPLANTS LEAD CARD DEFIB SINGLE LVL 2 EACH C1777 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815554 IMPLANTS LEAD CARD DEFIB SINGLE LVL 3 EACH C1777 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815562 IMPLANTS LEAD CARD DEFIB SINGLE LVL 4 EACH C1777 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815570 IMPLANTS LEAD CARD DEFIB SINGLE LVL 5 EACH C1777 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815588 IMPLANTS LEAD CARD DEFIB SINGLE LVL 6 EACH C1777 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815596 IMPLANTS LEAD CARD DEFIB SINGLE LVL 7 EACH C1777 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815604 IMPLANTS LEAD CARD DEFIB SINGLE LVL 8 EACH C1777 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815612 IMPLANTS LEAD CARD DEFIB SINGLE LVL 9 EACH C1777 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814177 IMPLANTS LEAD CORONARY VENOUS LV 10 EACH C1900 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814078 IMPLANTS LEAD CORONARY VENOUS LVL 0 EACH C1900 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814086 IMPLANTS LEAD CORONARY VENOUS LVL 1 EACH C1900 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814094 IMPLANTS LEAD CORONARY VENOUS LVL 2 EACH C1900 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814102 IMPLANTS LEAD CORONARY VENOUS LVL 3 EACH C1900 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814110 IMPLANTS LEAD CORONARY VENOUS LVL 4 EACH C1900 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814128 IMPLANTS LEAD CORONARY VENOUS LVL 5 EACH C1900 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814136 IMPLANTS LEAD CORONARY VENOUS LVL 6 EACH C1900 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814144 IMPLANTS LEAD CORONARY VENOUS LVL 7 EACH C1900 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814151 IMPLANTS LEAD CORONARY VENOUS LVL 8 EACH C1900 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814169 IMPLANTS LEAD CORONARY VENOUS LVL 9 EACH C1900 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805530 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 0 EACH C1778 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805548 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 1 EACH C1778 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805639 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 10 EACH C1778 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805555 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 2 EACH C1778 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805563 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 3 EACH C1778 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805571 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 4 EACH C1778 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805589 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 5 EACH C1778 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805597 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 6 EACH C1778 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805605 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 7 EACH C1778 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805613 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 8 EACH C1778 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805621 IMPLANTS LEAD NEUROSTIM IMPLANT LVL 9 EACH C1778 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811488 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 0 EACH C1897 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811496 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 1 EACH C1897 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811587 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 10 EACH C1897 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811504 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 2 EACH C1897 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811512 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 3 EACH C1897 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811520 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 4 EACH C1897 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811538 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 5 EACH C1897 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811546 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 6 EACH C1897 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811553 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 7 EACH C1897 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811561 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 8 EACH C1897 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811579 IMPLANTS LEAD NEUROSTIM TEST KIT LVL 9 EACH C1897 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808393 IMPLANTS LEAD PACEMAKER LVL 0 EACH C1898 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808401 IMPLANTS LEAD PACEMAKER LVL 1 EACH C1898 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808492 IMPLANTS LEAD PACEMAKER LVL 10 EACH C1898 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808419 IMPLANTS LEAD PACEMAKER LVL 2 EACH C1898 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808427 IMPLANTS LEAD PACEMAKER LVL 3 EACH C1898 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808435 IMPLANTS LEAD PACEMAKER LVL 4 EACH C1898 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808443 IMPLANTS LEAD PACEMAKER LVL 5 EACH C1898 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808450 IMPLANTS LEAD PACEMAKER LVL 6 EACH C1898 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808468 IMPLANTS LEAD PACEMAKER LVL 7 EACH C1898 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808476 IMPLANTS LEAD PACEMAKER LVL 8 EACH C1898 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808484 IMPLANTS LEAD PACEMAKER LVL 9 EACH C1898 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813732 IMPLANTS LEAD PACEMAKER VDD LV 10 EACH C1779 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813633 IMPLANTS LEAD PACEMAKER VDD LVL 0 EACH C1779 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813641 IMPLANTS LEAD PACEMAKER VDD LVL 1 EACH C1779 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813658 IMPLANTS LEAD PACEMAKER VDD LVL 2 EACH C1779 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813666 IMPLANTS LEAD PACEMAKER VDD LVL 3 EACH C1779 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813674 IMPLANTS LEAD PACEMAKER VDD LVL 4 EACH C1779 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813682 IMPLANTS LEAD PACEMAKER VDD LVL 5 EACH C1779 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813690 IMPLANTS LEAD PACEMAKER VDD LVL 6 EACH C1779 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813708 IMPLANTS LEAD PACEMAKER VDD LVL 7 EACH C1779 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813716 IMPLANTS LEAD PACEMAKER VDD LVL 8 EACH C1779 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813724 IMPLANTS LEAD PACEMAKER VDD LVL 9 EACH C1779 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813963 IMPLANTS LEAD PMKR/AICD COMBO LVL 0 EACH C1899 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813971 IMPLANTS LEAD PMKR/AICD COMBO LVL 1 EACH C1899 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813989 IMPLANTS LEAD PMKR/AICD COMBO LVL 2 EACH C1899 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813997 IMPLANTS LEAD PMKR/AICD COMBO LVL 3 EACH C1899 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814003 IMPLANTS LEAD PMKR/AICD COMBO LVL 4 EACH C1899 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814011 IMPLANTS LEAD PMKR/AICD COMBO LVL 5 EACH C1899 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814029 IMPLANTS LEAD PMKR/AICD COMBO LVL 6 EACH C1899 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814037 IMPLANTS LEAD PMKR/AICD COMBO LVL 7 EACH C1899 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814045 IMPLANTS LEAD PMKR/AICD COMBO LVL 8 EACH C1899 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814052 IMPLANTS LEAD PMKR/AICD COMBO LVL 9 EACH C1899 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814060 IMPLANTS LEAD PMKR/AICD COMBO LVL10 EACH C1899 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812643 IMPLANTS LENS INTRAOC (NEW TECH) LVL 0 EACH C1780 $75.00 276 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812650 IMPLANTS LENS INTRAOC (NEW TECH) LVL 1 EACH C1780 $150.00 276 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812668 IMPLANTS LENS INTRAOC (NEW TECH) LVL 2 EACH C1780 $300.00 276 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812676 IMPLANTS LENS INTRAOC (NEW TECH) LVL 3 EACH C1780 $600.00 276 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812684 IMPLANTS LENS INTRAOC (NEW TECH) LVL 4 EACH C1780 "$1,200.00 " 276 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812692 IMPLANTS LENS INTRAOC (NEW TECH) LVL 5 EACH C1780 "$2,400.00 " 276 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802685 IMPLANTS LO FLEXIBLE PREFAB EACH L0625 $54.00 274 $37.80 $27.00 $43.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820265 IMPLANTS MEDPOR CUSTOMIZED MIDFACE EACH C1763 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820166 IMPLANTS MEDPOR CUSTOMIZED PLUS M EACH C1713 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820620 IMPLANTS MEDTRONIC-NEUROSTIMULAT 97715 EACH C1767 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820224 IMPLANTS MESH 1.5/1.7 PREFORM STIFF R EACH C1713 "$31,500.00 " 278 "$22,050.00 " "$15,750.00 " "$25,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816560 IMPLANTS MESH 12X10IN SRG RECT PHASIX EACH C1781 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805647 IMPLANTS MESH LVL 0 EACH C1781 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805654 IMPLANTS MESH LVL 1 EACH C1781 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805746 IMPLANTS MESH LVL 10 EACH C1781 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805662 IMPLANTS MESH LVL 2 EACH C1781 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805670 IMPLANTS MESH LVL 3 EACH C1781 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805688 IMPLANTS MESH LVL 4 EACH C1781 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805696 IMPLANTS MESH LVL 5 EACH C1781 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805704 IMPLANTS MESH LVL 6 EACH C1781 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805712 IMPLANTS MESH LVL 7 EACH C1781 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805720 IMPLANTS MESH LVL 8 EACH C1781 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805738 IMPLANTS MESH LVL 9 EACH C1781 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819929 IMPLANTS MESH PLATING SYST TI-42321505 EACH C1713 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820141 IMPLANTS MESH/1.7 PREFORM 120X120X.6 EACH C1713 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820232 IMPLANTS MESH/1.7 PREFORM LAT STIFF L EACH C1713 "$31,500.00 " 278 "$22,050.00 " "$15,750.00 " "$25,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820174 IMPLANTS MESH/PRE-FORMED 190X140MM EACH C1713 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810712 IMPLANTS MORCELLATOR LVL 0 EACH C1782 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810720 IMPLANTS MORCELLATOR LVL 1 EACH C1782 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810811 IMPLANTS MORCELLATOR LVL 10 EACH C1782 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810738 IMPLANTS MORCELLATOR LVL 2 EACH C1782 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810746 IMPLANTS MORCELLATOR LVL 3 EACH C1782 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810753 IMPLANTS MORCELLATOR LVL 4 EACH C1782 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810761 IMPLANTS MORCELLATOR LVL 5 EACH C1782 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810779 IMPLANTS MORCELLATOR LVL 6 EACH C1782 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810787 IMPLANTS MORCELLATOR LVL 7 EACH C1782 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810795 IMPLANTS MORCELLATOR LVL 8 EACH C1782 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810803 IMPLANTS MORCELLATOR LVL 9 EACH C1782 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805860 IMPLANTS NEUROSTIM GENERATOR LVL 0 EACH C1820 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805878 IMPLANTS NEUROSTIM GENERATOR LVL 1 EACH C1820 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805969 IMPLANTS NEUROSTIM GENERATOR LVL 10 EACH C1820 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805886 IMPLANTS NEUROSTIM GENERATOR LVL 2 EACH C1820 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805894 IMPLANTS NEUROSTIM GENERATOR LVL 3 EACH C1820 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805902 IMPLANTS NEUROSTIM GENERATOR LVL 4 EACH C1820 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805910 IMPLANTS NEUROSTIM GENERATOR LVL 5 EACH C1820 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805928 IMPLANTS NEUROSTIM GENERATOR LVL 6 EACH C1820 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805936 IMPLANTS NEUROSTIM GENERATOR LVL 7 EACH C1820 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805944 IMPLANTS NEUROSTIM GENERATOR LVL 8 EACH C1820 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805951 IMPLANTS NEUROSTIM GENERATOR LVL 9 EACH C1820 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814656 IMPLANTS NEUROSTIM IMPL 1.9INX.6 37712 EACH C1820 "$24,384.00 " 278 "$17,068.80 " "$12,192.00 " "$19,507.20 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814649 IMPLANTS NEUROSTIM IMPL 1.9INX.6 37714 EACH C1820 "$22,950.00 " 278 "$16,065.00 " "$11,475.00 " "$18,360.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814631 IMPLANTS NEUROSTIM IMPL 49MMX65MM 37713 EACH C1820 "$22,050.00 " 278 "$15,435.00 " "$11,025.00 " "$17,640.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805977 IMPLANTS NEUROSTIM PROGRAMR LVL 0 EACH C1787 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805985 IMPLANTS NEUROSTIM PROGRAMR LVL 1 EACH C1787 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806074 IMPLANTS NEUROSTIM PROGRAMR LVL 10 EACH C1787 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27805993 IMPLANTS NEUROSTIM PROGRAMR LVL 2 EACH C1787 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806009 IMPLANTS NEUROSTIM PROGRAMR LVL 3 EACH C1787 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806017 IMPLANTS NEUROSTIM PROGRAMR LVL 4 EACH C1787 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806025 IMPLANTS NEUROSTIM PROGRAMR LVL 5 EACH C1787 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806033 IMPLANTS NEUROSTIM PROGRAMR LVL 6 EACH C1787 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806041 IMPLANTS NEUROSTIM PROGRAMR LVL 7 EACH C1787 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806058 IMPLANTS NEUROSTIM PROGRAMR LVL 8 EACH C1787 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806066 IMPLANTS NEUROSTIM PROGRAMR LVL 9 EACH C1787 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812023 IMPLANTS NEUROSTIMULATOR RECHG SESNOR EACH C1820 "$23,250.00 " 278 "$16,275.00 " "$11,625.00 " "$18,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812015 IMPLANTS NEUROSTIMULATOR RECHG ULTRA EACH C1820 "$23,634.00 " 278 "$16,543.80 " "$11,817.00 " "$18,907.20 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812478 IMPLANTS NEUROSTIMULATOR RECHG ULTRA EACH C1820 "$23,634.00 " 278 "$16,543.80 " "$11,817.00 " "$18,907.20 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817014 IMPLANTS OCULAR IMPLANT LVL 0 EACH L8610 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817022 IMPLANTS OCULAR IMPLANT LVL 1 EACH L8610 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817253 IMPLANTS OCULAR IMPLANT LVL 10 EACH L8610 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817030 IMPLANTS OCULAR IMPLANT LVL 2 EACH L8610 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817048 IMPLANTS OCULAR IMPLANT LVL 3 EACH L8610 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817196 IMPLANTS OCULAR IMPLANT LVL 4 EACH L8610 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817204 IMPLANTS OCULAR IMPLANT LVL 5 EACH L8610 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817212 IMPLANTS OCULAR IMPLANT LVL 6 EACH L8610 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817220 IMPLANTS OCULAR IMPLANT LVL 7 EACH L8610 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817238 IMPLANTS OCULAR IMPLANT LVL 8 EACH L8610 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817246 IMPLANTS OCULAR IMPLANT LVL 9 EACH L8610 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814508 IMPLANTS PACEMAKER NOT SING/DUAL LV 10 EACH C2621 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814409 IMPLANTS PACEMAKER NOT SING/DUAL LVL 0 EACH C2621 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814417 IMPLANTS PACEMAKER NOT SING/DUAL LVL 1 EACH C2621 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814425 IMPLANTS PACEMAKER NOT SING/DUAL LVL 2 EACH C2621 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814433 IMPLANTS PACEMAKER NOT SING/DUAL LVL 3 EACH C2621 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814441 IMPLANTS PACEMAKER NOT SING/DUAL LVL 4 EACH C2621 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814458 IMPLANTS PACEMAKER NOT SING/DUAL LVL 5 EACH C2621 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814466 IMPLANTS PACEMAKER NOT SING/DUAL LVL 6 EACH C2621 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814474 IMPLANTS PACEMAKER NOT SING/DUAL LVL 7 EACH C2621 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814482 IMPLANTS PACEMAKER NOT SING/DUAL LVL 8 EACH C2621 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814490 IMPLANTS PACEMAKER NOT SING/DUAL LVL 9 EACH C2621 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814292 IMPLANTS PACEMAKER SGL NON R/R LVL 0 EACH C2620 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814300 IMPLANTS PACEMAKER SGL NON R/R LVL 1 EACH C2620 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814391 IMPLANTS PACEMAKER SGL NON R/R LVL 10 EACH C2620 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814318 IMPLANTS PACEMAKER SGL NON R/R LVL 2 EACH C2620 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814326 IMPLANTS PACEMAKER SGL NON R/R LVL 3 EACH C2620 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814334 IMPLANTS PACEMAKER SGL NON R/R LVL 4 EACH C2620 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814342 IMPLANTS PACEMAKER SGL NON R/R LVL 5 EACH C2620 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814359 IMPLANTS PACEMAKER SGL NON R/R LVL 6 EACH C2620 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814367 IMPLANTS PACEMAKER SGL NON R/R LVL 7 EACH C2620 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814375 IMPLANTS PACEMAKER SGL NON R/R LVL 8 EACH C2620 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814383 IMPLANTS PACEMAKER SGL NON R/R LVL 9 EACH C2620 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808500 IMPLANTS PACEMAKER SNG CHAMBER LVL 0 EACH C1786 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808518 IMPLANTS PACEMAKER SNG CHAMBER LVL 1 EACH C1786 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808609 IMPLANTS PACEMAKER SNG CHAMBER LVL 10 EACH C1786 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808526 IMPLANTS PACEMAKER SNG CHAMBER LVL 2 EACH C1786 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808534 IMPLANTS PACEMAKER SNG CHAMBER LVL 3 EACH C1786 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808542 IMPLANTS PACEMAKER SNG CHAMBER LVL 4 EACH C1786 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808559 IMPLANTS PACEMAKER SNG CHAMBER LVL 5 EACH C1786 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808567 IMPLANTS PACEMAKER SNG CHAMBER LVL 6 EACH C1786 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808575 IMPLANTS PACEMAKER SNG CHAMBER LVL 7 EACH C1786 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808583 IMPLANTS PACEMAKER SNG CHAMBER LVL 8 EACH C1786 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808591 IMPLANTS PACEMAKER SNG CHAMBER LVL 9 EACH C1786 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808617 IMPLANTS PACEMKR DUAL CHMBR RR LVL 0 EACH C1785 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808625 IMPLANTS PACEMKR DUAL CHMBR RR LVL 1 EACH C1785 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808716 IMPLANTS PACEMKR DUAL CHMBR RR LVL 10 EACH C1785 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808633 IMPLANTS PACEMKR DUAL CHMBR RR LVL 2 EACH C1785 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808641 IMPLANTS PACEMKR DUAL CHMBR RR LVL 3 EACH C1785 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808658 IMPLANTS PACEMKR DUAL CHMBR RR LVL 4 EACH C1785 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808666 IMPLANTS PACEMKR DUAL CHMBR RR LVL 5 EACH C1785 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808674 IMPLANTS PACEMKR DUAL CHMBR RR LVL 6 EACH C1785 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808682 IMPLANTS PACEMKR DUAL CHMBR RR LVL 7 EACH C1785 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808690 IMPLANTS PACEMKR DUAL CHMBR RR LVL 8 EACH C1785 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808708 IMPLANTS PACEMKR DUAL CHMBR RR LVL 9 EACH C1785 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820190 IMPLANTS PEEK CUST. CRANIAL IMPL XLARGE EACH C1713 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820240 IMPLANTS PEEK CUSTOMIZED COMPLEX PLS XL EACH C1713 "$32,571.00 " 278 "$22,799.70 " "$16,285.50 " "$26,056.80 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820208 IMPLANTS PEEK CUSTOMIZED COMPLEX PLUS L EACH C1713 "$27,528.00 " 278 "$19,269.60 " "$13,764.00 " "$22,022.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820158 IMPLANTS PEEK CUSTOMIZED COMPLEX PLUS M EACH C1713 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820216 IMPLANTS PEEK PRIORITY CUST IMPL LARGE EACH C1713 "$30,183.00 " 278 "$21,128.10 " "$15,091.50 " "$24,146.40 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820182 IMPLANTS PEEK PRIORITY CUST IMPL MEDIUM EACH C1713 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820257 IMPLANTS PEEK PRIORITY CUST IMPL XLARGE EACH C1713 "$35,289.00 " 278 "$24,702.30 " "$17,644.50 " "$28,231.20 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806082 IMPLANTS PENILE IMPLANT INFLAT LVL 0 EACH C1813 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806090 IMPLANTS PENILE IMPLANT INFLAT LVL 1 EACH C1813 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806181 IMPLANTS PENILE IMPLANT INFLAT LVL 10 EACH C1813 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806108 IMPLANTS PENILE IMPLANT INFLAT LVL 2 EACH C1813 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806116 IMPLANTS PENILE IMPLANT INFLAT LVL 3 EACH C1813 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806124 IMPLANTS PENILE IMPLANT INFLAT LVL 4 EACH C1813 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806132 IMPLANTS PENILE IMPLANT INFLAT LVL 5 EACH C1813 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806140 IMPLANTS PENILE IMPLANT INFLAT LVL 6 EACH C1813 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806157 IMPLANTS PENILE IMPLANT INFLAT LVL 7 EACH C1813 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806165 IMPLANTS PENILE IMPLANT INFLAT LVL 8 EACH C1813 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806173 IMPLANTS PENILE IMPLANT INFLAT LVL 9 EACH C1813 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806199 IMPLANTS PENILE IMPLANT NINFLAT LVL 0 EACH C2622 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806207 IMPLANTS PENILE IMPLANT NINFLAT LVL 1 EACH C2622 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806298 IMPLANTS PENILE IMPLANT NINFLAT LVL 10 EACH C2622 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806215 IMPLANTS PENILE IMPLANT NINFLAT LVL 2 EACH C2622 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806223 IMPLANTS PENILE IMPLANT NINFLAT LVL 3 EACH C2622 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806231 IMPLANTS PENILE IMPLANT NINFLAT LVL 4 EACH C2622 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806249 IMPLANTS PENILE IMPLANT NINFLAT LVL 5 EACH C2622 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806256 IMPLANTS PENILE IMPLANT NINFLAT LVL 6 EACH C2622 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806264 IMPLANTS PENILE IMPLANT NINFLAT LVL 7 EACH C2622 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806272 IMPLANTS PENILE IMPLANT NINFLAT LVL 8 EACH C2622 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27806280 IMPLANTS PENILE IMPLANT NINFLAT LVL 9 EACH C2622 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814185 IMPLANTS PMKR DUAL NON R/RR LVL 0 EACH C2619 $75.00 275 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814193 IMPLANTS PMKR DUAL NON R/RR LVL 1 EACH C2619 $150.00 275 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814284 IMPLANTS PMKR DUAL NON R/RR LVL 10 EACH C2619 "$26,000.00 " 275 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814201 IMPLANTS PMKR DUAL NON R/RR LVL 2 EACH C2619 $300.00 275 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814219 IMPLANTS PMKR DUAL NON R/RR LVL 3 EACH C2619 $600.00 275 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814227 IMPLANTS PMKR DUAL NON R/RR LVL 4 EACH C2619 "$1,200.00 " 275 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814235 IMPLANTS PMKR DUAL NON R/RR LVL 5 EACH C2619 "$2,400.00 " 275 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814243 IMPLANTS PMKR DUAL NON R/RR LVL 6 EACH C2619 "$5,000.00 " 275 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814250 IMPLANTS PMKR DUAL NON R/RR LVL 7 EACH C2619 "$9,400.00 " 275 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814268 IMPLANTS PMKR DUAL NON R/RR LVL 8 EACH C2619 "$15,000.00 " 275 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27814276 IMPLANTS PMKR DUAL NON R/RR LVL 9 EACH C2619 "$20,000.00 " 275 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809821 IMPLANTS POST CHMBR INTRAOCULAR LEN L10 EACH V2632 "$26,000.00 " 276 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809722 IMPLANTS POST CHMBR INTRAOCULAR LENS L0 EACH V2632 $75.00 276 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809730 IMPLANTS POST CHMBR INTRAOCULAR LENS L1 EACH V2632 $150.00 276 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809748 IMPLANTS POST CHMBR INTRAOCULAR LENS L2 EACH V2632 $300.00 276 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809755 IMPLANTS POST CHMBR INTRAOCULAR LENS L3 EACH V2632 $600.00 276 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809763 IMPLANTS POST CHMBR INTRAOCULAR LENS L4 EACH V2632 "$1,200.00 " 276 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809771 IMPLANTS POST CHMBR INTRAOCULAR LENS L5 EACH V2632 "$2,400.00 " 276 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809789 IMPLANTS POST CHMBR INTRAOCULAR LENS L6 EACH V2632 "$5,000.00 " 276 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809797 IMPLANTS POST CHMBR INTRAOCULAR LENS L7 EACH V2632 "$9,400.00 " 276 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809805 IMPLANTS POST CHMBR INTRAOCULAR LENS L8 EACH V2632 "$15,000.00 " 276 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809813 IMPLANTS POST CHMBR INTRAOCULAR LENS L9 EACH V2632 "$20,000.00 " 276 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812098 IMPLANTS PRESBYOPIA CORRECTING IOL LV 0 EACH V2788 $75.00 276 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812106 IMPLANTS PRESBYOPIA CORRECTING IOL LV 1 EACH V2788 $150.00 276 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812114 IMPLANTS PRESBYOPIA CORRECTING IOL LV 2 EACH V2788 $300.00 276 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812122 IMPLANTS PRESBYOPIA CORRECTING IOL LV 3 EACH V2788 $600.00 276 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812130 IMPLANTS PRESBYOPIA CORRECTING IOL LV 4 EACH V2788 "$1,200.00 " 276 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27812148 IMPLANTS PRESBYOPIA CORRECTING IOL LV 5 EACH V2788 "$2,400.00 " 276 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809383 IMPLANTS PROBE CRYOABLATION LVL 0 EACH C2618 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809391 IMPLANTS PROBE CRYOABLATION LVL 1 EACH C2618 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809482 IMPLANTS PROBE CRYOABLATION LVL 10 EACH C2618 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809409 IMPLANTS PROBE CRYOABLATION LVL 2 EACH C2618 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809417 IMPLANTS PROBE CRYOABLATION LVL 3 EACH C2618 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809425 IMPLANTS PROBE CRYOABLATION LVL 4 EACH C2618 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809433 IMPLANTS PROBE CRYOABLATION LVL 5 EACH C2618 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809441 IMPLANTS PROBE CRYOABLATION LVL 6 EACH C2618 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809458 IMPLANTS PROBE CRYOABLATION LVL 7 EACH C2618 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809466 IMPLANTS PROBE CRYOABLATION LVL 8 EACH C2618 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809474 IMPLANTS PROBE CRYOABLATION LVL 9 EACH C2618 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815737 IMPLANTS QUADRA ASSURA CRT-D EACH C1882 "$31,500.00 " 275 "$22,050.00 " "$15,750.00 " "$25,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815745 IMPLANTS QUADRA ASSURA CRT-D EACH C1882 "$31,500.00 " 275 "$22,050.00 " "$15,750.00 " "$25,200.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815760 IMPLANTS QUADRA ASSURA CRT-D SYS MERLIN EACH C1882 "$37,500.00 " 275 "$26,250.00 " "$18,750.00 " "$30,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815927 IMPLANTS QUADRA ASSURA CRT-D SYS MERLIN EACH C2621 "$37,500.00 " 275 "$26,250.00 " "$18,750.00 " "$30,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815752 IMPLANTS QUADRA ASSURA CRT-D SYSTEM EACH C1882 "$37,500.00 " 275 "$26,250.00 " "$18,750.00 " "$30,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815919 IMPLANTS QUADRA ASSURA CRT-D SYSTEM EACH C2621 "$37,500.00 " 275 "$26,250.00 " "$18,750.00 " "$30,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816685 IMPLANTS "REPAIR DEVICE, URINARY LVL 0 " EACH C2631 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816693 IMPLANTS "REPAIR DEVICE, URINARY LVL 1 " EACH C2631 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816784 IMPLANTS "REPAIR DEVICE, URINARY LVL 10 " EACH C2631 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816701 IMPLANTS "REPAIR DEVICE, URINARY LVL 2 " EACH C2631 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816719 IMPLANTS "REPAIR DEVICE, URINARY LVL 3 " EACH C2631 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816727 IMPLANTS "REPAIR DEVICE, URINARY LVL 4 " EACH C2631 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816735 IMPLANTS "REPAIR DEVICE, URINARY LVL 5 " EACH C2631 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816743 IMPLANTS "REPAIR DEVICE, URINARY LVL 6 " EACH C2631 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816750 IMPLANTS "REPAIR DEVICE, URINARY LVL 7 " EACH C2631 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816768 IMPLANTS "REPAIR DEVICE, URINARY LVL 8 " EACH C2631 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816776 IMPLANTS "REPAIR DEVICE, URINARY LVL 9 " EACH C2631 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810605 IMPLANTS RET DEV INSERTABLE LVL 0 EACH C1773 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810613 IMPLANTS RET DEV INSERTABLE LVL 1 EACH C1773 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810704 IMPLANTS RET DEV INSERTABLE LVL 10 EACH C1773 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810621 IMPLANTS RET DEV INSERTABLE LVL 2 EACH C1773 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810639 IMPLANTS RET DEV INSERTABLE LVL 3 EACH C1773 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810647 IMPLANTS RET DEV INSERTABLE LVL 4 EACH C1773 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810654 IMPLANTS RET DEV INSERTABLE LVL 5 EACH C1773 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810662 IMPLANTS RET DEV INSERTABLE LVL 6 EACH C1773 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810670 IMPLANTS RET DEV INSERTABLE LVL 7 EACH C1773 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810688 IMPLANTS RET DEV INSERTABLE LVL 8 EACH C1773 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810696 IMPLANTS RET DEV INSERTABLE LVL 9 EACH C1773 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813740 IMPLANTS SEPTAL DEFECT IMP SYS LVL 0 EACH C1817 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813757 IMPLANTS SEPTAL DEFECT IMP SYS LVL 1 EACH C1817 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813849 IMPLANTS SEPTAL DEFECT IMP SYS LVL 10 EACH C1817 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813765 IMPLANTS SEPTAL DEFECT IMP SYS LVL 2 EACH C1817 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813773 IMPLANTS SEPTAL DEFECT IMP SYS LVL 3 EACH C1817 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813781 IMPLANTS SEPTAL DEFECT IMP SYS LVL 4 EACH C1817 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813799 IMPLANTS SEPTAL DEFECT IMP SYS LVL 5 EACH C1817 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813807 IMPLANTS SEPTAL DEFECT IMP SYS LVL 6 EACH C1817 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813815 IMPLANTS SEPTAL DEFECT IMP SYS LVL 7 EACH C1817 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813823 IMPLANTS SEPTAL DEFECT IMP SYS LVL 8 EACH C1817 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813831 IMPLANTS SEPTAL DEFECT IMP SYS LVL 9 EACH C1817 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811371 IMPLANTS SHEATH FIXEDNON-PEEL LVL 0 EACH C1893 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811389 IMPLANTS SHEATH FIXEDNON-PEEL LVL 1 EACH C1893 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811470 IMPLANTS SHEATH FIXEDNON-PEEL LVL 10 EACH C1893 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811397 IMPLANTS SHEATH FIXEDNON-PEEL LVL 2 EACH C1893 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811405 IMPLANTS SHEATH FIXEDNON-PEEL LVL 3 EACH C1893 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811413 IMPLANTS SHEATH FIXEDNON-PEEL LVL 4 EACH C1893 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811421 IMPLANTS SHEATH FIXEDNON-PEEL LVL 5 EACH C1893 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811439 IMPLANTS SHEATH FIXEDNON-PEEL LVL 6 EACH C1893 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811447 IMPLANTS SHEATH FIXEDNON-PEEL LVL 7 EACH C1893 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811454 IMPLANTS SHEATH FIXEDNON-PEEL LVL 8 EACH C1893 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811462 IMPLANTS SHEATH FIXEDNON-PEEL LVL 9 EACH C1893 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817378 IMPLANTS SKIN SUBSTITUTE NOS LVL 0 EACH Q4100 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817386 IMPLANTS SKIN SUBSTITUTE NOS LVL 1 EACH Q4100 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817477 IMPLANTS SKIN SUBSTITUTE NOS LVL 10 EACH Q4100 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817394 IMPLANTS SKIN SUBSTITUTE NOS LVL 2 EACH Q4100 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817402 IMPLANTS SKIN SUBSTITUTE NOS LVL 3 EACH Q4100 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817410 IMPLANTS SKIN SUBSTITUTE NOS LVL 4 EACH Q4100 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817428 IMPLANTS SKIN SUBSTITUTE NOS LVL 5 EACH Q4100 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817436 IMPLANTS SKIN SUBSTITUTE NOS LVL 6 EACH Q4100 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817444 IMPLANTS SKIN SUBSTITUTE NOS LVL 7 EACH Q4100 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817451 IMPLANTS SKIN SUBSTITUTE NOS LVL 8 EACH Q4100 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817469 IMPLANTS SKIN SUBSTITUTE NOS LVL 9 EACH Q4100 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816909 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 0 EACH C9363 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816917 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 1 EACH C9363 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817006 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 10 EACH C9363 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816925 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 2 EACH C9363 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816933 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 3 EACH C9363 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816941 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 4 EACH C9363 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816958 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 5 EACH C9363 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816966 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 6 EACH C9363 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816974 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 7 EACH C9363 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816982 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 8 EACH C9363 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27816990 IMPLANTS SKIN SUBSTITUTE-INTEGRA LVL 9 EACH C9363 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802784 IMPLANTS SPLINT FINGER EACH $24.19 270 $16.93 $12.10 $19.35 65% 80% 50% 50% 65% 65% 65% 27818038 IMPLANTS STENT COAT W DEL CM G35334 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818046 IMPLANTS STENT COAT W DEL CM G35335 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818053 IMPLANTS STENT COAT W DEL CM G35337 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818061 IMPLANTS STENT COAT W DEL CM G35338 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818079 IMPLANTS STENT COAT W DEL CM G35341 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818087 IMPLANTS STENT COAT W DEL CM G35342 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818095 IMPLANTS STENT COAT W DEL CM G35343 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818103 IMPLANTS STENT COAT W DEL CM G35345 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818111 IMPLANTS STENT COAT W DEL CM G35346 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818129 IMPLANTS STENT COAT W DEL CM G35349 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818137 IMPLANTS STENT COAT W DEL CM G35350 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818145 IMPLANTS STENT COAT W DEL CM G35351 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818152 IMPLANTS STENT COAT W DEL CM G35352 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818160 IMPLANTS STENT COAT W DEL CM G35353 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818178 IMPLANTS STENT COAT W DEL CM G35354 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818186 IMPLANTS STENT COAT W DEL CM G35357 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818194 IMPLANTS STENT COAT W DEL CM G35358 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818202 IMPLANTS STENT COAT W DEL CM G35359 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818210 IMPLANTS STENT COAT W DEL CM G35361 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818228 IMPLANTS STENT COAT W DEL CM G35362 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818236 IMPLANTS STENT COAT W DEL CM G35363 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818244 IMPLANTS STENT COAT W DEL CM G35364 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818251 IMPLANTS STENT COAT W DEL CM G35365 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818269 IMPLANTS STENT COAT W DEL CM G35366 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818277 IMPLANTS STENT COAT W DEL CM G35367 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818285 IMPLANTS STENT COAT W DEL CM G35370 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818293 IMPLANTS STENT COAT W DEL CM G35371 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818301 IMPLANTS STENT COAT W DEL CM G35372 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818319 IMPLANTS STENT COAT W DEL CM G35373 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818327 IMPLANTS STENT COAT W DEL CM G35374 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818335 IMPLANTS STENT COAT W DEL CM G35375 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817972 IMPLANTS STENT COAT W DEL CM G35381 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817980 IMPLANTS STENT COAT W DEL CM G35382 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27817998 IMPLANTS STENT COAT W DEL CM G35384 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818004 IMPLANTS STENT COAT W DEL CM G35386 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818012 IMPLANTS STENT COAT W DEL CM G35392 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818020 IMPLANTS STENT COAT W DEL CM G35404 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818343 IMPLANTS STENT COAT W DEL CM G38172 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818350 IMPLANTS STENT COAT W DEL CM G38178 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818368 IMPLANTS STENT COAT W DEL CM G38180 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818376 IMPLANTS STENT COAT W DEL CM G38190 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818384 IMPLANTS STENT COAT W DEL CM G38191 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818392 IMPLANTS STENT COAT W DEL CM G38208 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818400 IMPLANTS STENT COAT W DEL CM G38220 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818418 IMPLANTS STENT COAT W DEL CM G47436 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818426 IMPLANTS STENT COAT W DEL CM G47437 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818434 IMPLANTS STENT COAT W DEL CM G47438 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818442 IMPLANTS STENT COAT W DEL CM G47439 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818459 IMPLANTS STENT COAT W DEL CM G47440 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818467 IMPLANTS STENT COAT W DEL CM G47441 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818475 IMPLANTS STENT COAT W DEL CM G47442 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818483 IMPLANTS STENT COAT W DEL CM G47443 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818491 IMPLANTS STENT COAT W DEL CM G47444 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818509 IMPLANTS STENT COAT W DEL CM G47445 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818517 IMPLANTS STENT COAT W DEL CM G47446 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818525 IMPLANTS STENT COAT W DEL CM G47447 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818533 IMPLANTS STENT COAT W DEL CM G47448 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818541 IMPLANTS STENT COAT W DEL CM G47449 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818558 IMPLANTS STENT COAT W DEL CM G47450 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818566 IMPLANTS STENT COAT W DEL CM G47451 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818574 IMPLANTS STENT COAT W DEL CM G47452 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818582 IMPLANTS STENT COAT W DEL CM G47453 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818590 IMPLANTS STENT COAT W DEL CM G47454 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818608 IMPLANTS STENT COAT W DEL CM G47455 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818616 IMPLANTS STENT COAT W DEL CM G47456 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818624 IMPLANTS STENT COAT W DEL CM G47457 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818632 IMPLANTS STENT COAT W DEL CM G47458 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818640 IMPLANTS STENT COAT W DEL CM G47459 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818657 IMPLANTS STENT COAT W DEL CM G47460 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818665 IMPLANTS STENT COAT W DEL CM G47461 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818673 IMPLANTS STENT COAT W DEL CM G47462 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818681 IMPLANTS STENT COAT W DEL CM G47463 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818699 IMPLANTS STENT COAT W DEL CM G47464 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818707 IMPLANTS STENT COAT W DEL CM G47465 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818715 IMPLANTS STENT COAT W DEL CM G47466 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818723 IMPLANTS STENT COAT W DEL CM G47467 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818731 IMPLANTS STENT COAT W DEL CM G47468 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818749 IMPLANTS STENT COAT W DEL CM G47469 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818756 IMPLANTS STENT COAT W DEL CM G47470 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818764 IMPLANTS STENT COAT W DEL CM G47471 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818772 IMPLANTS STENT COAT W DEL CM G47472 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818780 IMPLANTS STENT COAT W DEL CM G47473 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818798 IMPLANTS STENT COAT W DEL CM G47474 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818806 IMPLANTS STENT COAT W DEL CM G47475 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818814 IMPLANTS STENT COAT W DEL CM G47476 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818822 IMPLANTS STENT COAT W DEL CM G47477 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818830 IMPLANTS STENT COAT W DEL CM G47478 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818848 IMPLANTS STENT COAT W DEL CM G47479 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818855 IMPLANTS STENT COAT W DEL CM G47480 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818863 IMPLANTS STENT COAT W DEL CM G47481 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818871 IMPLANTS STENT COAT W DEL CM G47482 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818889 IMPLANTS STENT COAT W DEL CM G47483 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818905 IMPLANTS STENT COAT W DEL CM G47484 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818897 IMPLANTS STENT COAT W DEL CM G47485 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818913 IMPLANTS STENT COAT W DEL CM G47486 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818921 IMPLANTS STENT COAT W DEL CM G47487 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818939 IMPLANTS STENT COAT W DEL CM G47488 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818947 IMPLANTS STENT COAT W DEL CM G47489 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807296 IMPLANTS STENT COAT W DEL LVL 0 EACH C1874 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807304 IMPLANTS STENT COAT W DEL LVL 1 EACH C1874 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807395 IMPLANTS STENT COAT W DEL LVL 10 EACH C1874 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807312 IMPLANTS STENT COAT W DEL LVL 2 EACH C1874 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807320 IMPLANTS STENT COAT W DEL LVL 3 EACH C1874 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807338 IMPLANTS STENT COAT W DEL LVL 4 EACH C1874 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807346 IMPLANTS STENT COAT W DEL LVL 5 EACH C1874 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807353 IMPLANTS STENT COAT W DEL LVL 6 EACH C1874 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807361 IMPLANTS STENT COAT W DEL LVL 7 EACH C1874 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807379 IMPLANTS STENT COAT W DEL LVL 8 EACH C1874 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807387 IMPLANTS STENT COAT W DEL LVL 9 EACH C1874 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813856 IMPLANTS STENT COV W/O DEL SY LVL 0 EACH C1875 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813864 IMPLANTS STENT COV W/O DEL SY LVL 1 EACH C1875 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813955 IMPLANTS STENT COV W/O DEL SY LVL 10 EACH C1875 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813872 IMPLANTS STENT COV W/O DEL SY LVL 2 EACH C1875 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813880 IMPLANTS STENT COV W/O DEL SY LVL 3 EACH C1875 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813898 IMPLANTS STENT COV W/O DEL SY LVL 4 EACH C1875 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813906 IMPLANTS STENT COV W/O DEL SY LVL 5 EACH C1875 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813914 IMPLANTS STENT COV W/O DEL SY LVL 6 EACH C1875 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813922 IMPLANTS STENT COV W/O DEL SY LVL 7 EACH C1875 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813930 IMPLANTS STENT COV W/O DEL SY LVL 8 EACH C1875 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27813948 IMPLANTS STENT COV W/O DEL SY LVL 9 EACH C1875 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807403 IMPLANTS STENT NON COAT W DEL LVL 0 EACH C1876 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807411 IMPLANTS STENT NON COAT W DEL LVL 1 EACH C1876 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807502 IMPLANTS STENT NON COAT W DEL LVL 10 EACH C1876 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807429 IMPLANTS STENT NON COAT W DEL LVL 2 EACH C1876 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807437 IMPLANTS STENT NON COAT W DEL LVL 3 EACH C1876 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807445 IMPLANTS STENT NON COAT W DEL LVL 4 EACH C1876 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807452 IMPLANTS STENT NON COAT W DEL LVL 5 EACH C1876 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807460 IMPLANTS STENT NON COAT W DEL LVL 6 EACH C1876 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807478 IMPLANTS STENT NON COAT W DEL LVL 7 EACH C1876 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807486 IMPLANTS STENT NON COAT W DEL LVL 8 EACH C1876 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807494 IMPLANTS STENT NON COAT W DEL LVL 9 EACH C1876 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807510 IMPLANTS STENT NON COAT WO DEL LVL 0 EACH C1877 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807528 IMPLANTS STENT NON COAT WO DEL LVL 1 EACH C1877 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807619 IMPLANTS STENT NON COAT WO DEL LVL 10 EACH C1877 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807536 IMPLANTS STENT NON COAT WO DEL LVL 2 EACH C1877 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807544 IMPLANTS STENT NON COAT WO DEL LVL 3 EACH C1877 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807551 IMPLANTS STENT NON COAT WO DEL LVL 4 EACH C1877 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807569 IMPLANTS STENT NON COAT WO DEL LVL 5 EACH C1877 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807577 IMPLANTS STENT NON COAT WO DEL LVL 6 EACH C1877 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807585 IMPLANTS STENT NON COAT WO DEL LVL 7 EACH C1877 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807593 IMPLANTS STENT NON COAT WO DEL LVL 8 EACH C1877 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807601 IMPLANTS STENT NON COAT WO DEL LVL 9 EACH C1877 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808948 IMPLANTS STENT NONCORTEMP W/ DEL LVL 0 EACH C2625 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808955 IMPLANTS STENT NONCORTEMP W/ DEL LVL 1 EACH C2625 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809045 IMPLANTS STENT NONCORTEMP W/ DEL LVL 10 EACH C2625 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808963 IMPLANTS STENT NONCORTEMP W/ DEL LVL 2 EACH C2625 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808971 IMPLANTS STENT NONCORTEMP W/ DEL LVL 3 EACH C2625 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808989 IMPLANTS STENT NONCORTEMP W/ DEL LVL 4 EACH C2625 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808997 IMPLANTS STENT NONCORTEMP W/ DEL LVL 5 EACH C2625 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809003 IMPLANTS STENT NONCORTEMP W/ DEL LVL 6 EACH C2625 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809011 IMPLANTS STENT NONCORTEMP W/ DEL LVL 7 EACH C2625 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809029 IMPLANTS STENT NONCORTEMP W/ DEL LVL 8 EACH C2625 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27809037 IMPLANTS STENT NONCORTEMP W/ DEL LVL 9 EACH C2625 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808724 IMPLANTS STENT NONCORTEMP WO DEL LVL 0 EACH C2617 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808732 IMPLANTS STENT NONCORTEMP WO DEL LVL 1 EACH C2617 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808823 IMPLANTS STENT NONCORTEMP WO DEL LVL 10 EACH C2617 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808740 IMPLANTS STENT NONCORTEMP WO DEL LVL 2 EACH C2617 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808757 IMPLANTS STENT NONCORTEMP WO DEL LVL 3 EACH C2617 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808765 IMPLANTS STENT NONCORTEMP WO DEL LVL 4 EACH C2617 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808773 IMPLANTS STENT NONCORTEMP WO DEL LVL 5 EACH C2617 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808781 IMPLANTS STENT NONCORTEMP WO DEL LVL 6 EACH C2617 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808799 IMPLANTS STENT NONCORTEMP WO DEL LVL 7 EACH C2617 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808807 IMPLANTS STENT NONCORTEMP WO DEL LVL 8 EACH C2617 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27808815 IMPLANTS STENT NONCORTEMP WO DEL LVL 9 EACH C2617 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819945 IMPLANTS TAG THOR ENDO 21MMX10CM 18FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819952 IMPLANTS TAG THOR ENDO 26-21MMX10CM EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819960 IMPLANTS TAG THOR ENDO 26MMX10CM 20 T EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819978 IMPLANTS TAG THOR ENDO 28MMX10CM 20FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819986 IMPLANTS TAG THOR ENDO 28MMX15CM 20FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819994 IMPLANTS TAG THOR ENDO 31-26MMX10CM 22T EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820000 IMPLANTS TAG THOR ENDO 31MMX10CM 22FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820018 IMPLANTS TAG THOR ENDO 31MMX15CM 22FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820026 IMPLANTS TAG THOR ENDO 34MMX10CM 22FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820034 IMPLANTS TAG THOR ENDO 34MMX15CM 22FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820042 IMPLANTS TAG THOR ENDO 34MMX20CM 22FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820059 IMPLANTS TAG THOR ENDO 37MMX10CM 24FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820067 IMPLANTS TAG THOR ENDO 37MMX15CM 24FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820075 IMPLANTS TAG THOR ENDO 37MMX20CM 24FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820083 IMPLANTS TAG THOR ENDO 40MMX10CM 24FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820091 IMPLANTS TAG THOR ENDO 40MMX15CM 24FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820109 IMPLANTS TAG THOR ENDO 40MMX20CM 24FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820117 IMPLANTS TAG THOR ENDO 45MMX10CM 24FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820125 IMPLANTS TAG THOR ENDO 45MMX15CM 24FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27820133 IMPLANTS TAG THOR ENDO 45MMX20CM 24FR EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27815711 IMPLANTS UNIFY ASSURA CRT-D EACH C1882 "$27,000.00 " 275 "$18,900.00 " "$13,500.00 " "$21,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815729 IMPLANTS UNIFY ASSURA CRT-D EACH C1882 "$27,000.00 " 275 "$18,900.00 " "$13,500.00 " "$21,600.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815893 IMPLANTS UNIFY ASSURA CRT-D SYS MERLIN EACH C2621 "$33,000.00 " 275 "$23,100.00 " "$16,500.00 " "$26,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815901 IMPLANTS UNIFY ASSURA CRT-D SYS MERLIN EACH C2621 "$33,000.00 " 275 "$23,100.00 " "$16,500.00 " "$26,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27815885 IMPLANTS UNIFY ASSURA CRT-D SYSTEM EACH C2621 "$33,000.00 " 275 "$23,100.00 " "$16,500.00 " "$26,400.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807627 IMPLANTS URINARY IMP REPR W SLG LVL 0 EACH C1771 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807635 IMPLANTS URINARY IMP REPR W SLG LVL 1 EACH C1771 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807726 IMPLANTS URINARY IMP REPR W SLG LVL 10 EACH C1771 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807643 IMPLANTS URINARY IMP REPR W SLG LVL 2 EACH C1771 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807650 IMPLANTS URINARY IMP REPR W SLG LVL 3 EACH C1771 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807668 IMPLANTS URINARY IMP REPR W SLG LVL 4 EACH C1771 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807676 IMPLANTS URINARY IMP REPR W SLG LVL 5 EACH C1771 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807684 IMPLANTS URINARY IMP REPR W SLG LVL 6 EACH C1771 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807692 IMPLANTS URINARY IMP REPR W SLG LVL 7 EACH C1771 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807700 IMPLANTS URINARY IMP REPR W SLG LVL 8 EACH C1771 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807718 IMPLANTS URINARY IMP REPR W SLG LVL 9 EACH C1771 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807734 IMPLANTS URINARY IMP REPR WO SLG LVL 0 EACH C2631 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807742 IMPLANTS URINARY IMP REPR WO SLG LVL 1 EACH C2631 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807833 IMPLANTS URINARY IMP REPR WO SLG LVL 10 EACH C2631 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807759 IMPLANTS URINARY IMP REPR WO SLG LVL 2 EACH C2631 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807767 IMPLANTS URINARY IMP REPR WO SLG LVL 3 EACH C2631 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807775 IMPLANTS URINARY IMP REPR WO SLG LVL 4 EACH C2631 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807783 IMPLANTS URINARY IMP REPR WO SLG LVL 5 EACH C2631 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807791 IMPLANTS URINARY IMP REPR WO SLG LVL 6 EACH C2631 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807809 IMPLANTS URINARY IMP REPR WO SLG LVL 7 EACH C2631 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807817 IMPLANTS URINARY IMP REPR WO SLG LVL 8 EACH C2631 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807825 IMPLANTS URINARY IMP REPR WO SLG LVL 9 EACH C2631 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807841 IMPLANTS URINARY SPHINCTER IMP LVL 0 EACH C1815 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807858 IMPLANTS URINARY SPHINCTER IMP LVL 1 EACH C1815 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807940 IMPLANTS URINARY SPHINCTER IMP LVL 10 EACH C1815 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807866 IMPLANTS URINARY SPHINCTER IMP LVL 2 EACH C1815 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807874 IMPLANTS URINARY SPHINCTER IMP LVL 3 EACH C1815 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807882 IMPLANTS URINARY SPHINCTER IMP LVL 4 EACH C1815 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807890 IMPLANTS URINARY SPHINCTER IMP LVL 5 EACH C1815 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807908 IMPLANTS URINARY SPHINCTER IMP LVL 6 EACH C1815 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807916 IMPLANTS URINARY SPHINCTER IMP LVL 7 EACH C1815 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807924 IMPLANTS URINARY SPHINCTER IMP LVL 8 EACH C1815 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27807932 IMPLANTS URINARY SPHINCTER IMP LVL 9 EACH C1815 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810936 IMPLANTS VENA CAVA FILTER LVL 0 EACH C1880 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818954 IMPLANTS VENA CAVA FILTER LVL 0 EACH C1880 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810944 IMPLANTS VENA CAVA FILTER LVL 1 EACH C1880 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818962 IMPLANTS VENA CAVA FILTER LVL 1 EACH C1880 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811033 IMPLANTS VENA CAVA FILTER LVL 10 EACH C1880 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819051 IMPLANTS VENA CAVA FILTER LVL 10 EACH C1880 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810951 IMPLANTS VENA CAVA FILTER LVL 2 EACH C1880 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818970 IMPLANTS VENA CAVA FILTER LVL 2 EACH C1880 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810969 IMPLANTS VENA CAVA FILTER LVL 3 EACH C1880 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818988 IMPLANTS VENA CAVA FILTER LVL 3 EACH C1880 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810977 IMPLANTS VENA CAVA FILTER LVL 4 EACH C1880 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27818996 IMPLANTS VENA CAVA FILTER LVL 4 EACH C1880 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810985 IMPLANTS VENA CAVA FILTER LVL 5 EACH C1880 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819002 IMPLANTS VENA CAVA FILTER LVL 5 EACH C1880 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27810993 IMPLANTS VENA CAVA FILTER LVL 6 EACH C1880 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819010 IMPLANTS VENA CAVA FILTER LVL 6 EACH C1880 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811009 IMPLANTS VENA CAVA FILTER LVL 7 EACH C1880 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819028 IMPLANTS VENA CAVA FILTER LVL 7 EACH C1880 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811017 IMPLANTS VENA CAVA FILTER LVL 8 EACH C1880 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819036 IMPLANTS VENA CAVA FILTER LVL 8 EACH C1880 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27811025 IMPLANTS VENA CAVA FILTER LVL 9 EACH C1880 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27819044 IMPLANTS VENA CAVA FILTER LVL 9 EACH C1880 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27802792 IMPLANTS WHO EXTEND CTRL COCK-UP EACH L3908 $67.00 274 $46.90 $33.50 $53.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27820638 IMPLANTS WIRELESS PRESSURE SENSOR LVL 0 EACH C2624 $75.00 960 $52.50 $37.50 $60.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27820646 IMPLANTS WIRELESS PRESSURE SENSOR LVL 1 EACH C2624 $150.00 960 $105.00 $75.00 $120.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27820653 IMPLANTS WIRELESS PRESSURE SENSOR LVL 2 EACH C2624 $300.00 960 $210.00 $150.00 $240.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27820661 IMPLANTS WIRELESS PRESSURE SENSOR LVL 3 EACH C2624 $600.00 960 $420.00 $300.00 $480.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27820679 IMPLANTS WIRELESS PRESSURE SENSOR LVL 4 EACH C2624 "$1,200.00 " 960 $840.00 $600.00 $960.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27820687 IMPLANTS WIRELESS PRESSURE SENSOR LVL 5 EACH C2624 "$2,400.00 " 960 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27820695 IMPLANTS WIRELESS PRESSURE SENSOR LVL 6 EACH C2624 "$5,000.00 " 960 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27820703 IMPLANTS WIRELESS PRESSURE SENSOR LVL 7 EACH C2624 "$9,400.00 " 960 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27820711 IMPLANTS WIRELESS PRESSURE SENSOR LVL 8 EACH C2624 "$15,000.00 " 960 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27820729 IMPLANTS WIRELESS PRESSURE SENSOR LVL 9 EACH C2624 "$20,000.00 " 960 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 27819077 IMPLANTS ZA THOR DISTAL 30X160 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819226 IMPLANTS ZA THOR DISTAL 32X160 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819234 IMPLANTS ZA THOR DISTAL 34X142 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819242 IMPLANTS ZA THOR DISTAL 36X142 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819259 IMPLANTS ZA THOR DISTAL 36X190 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819267 IMPLANTS ZA THOR DISTAL 38X142 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819275 IMPLANTS ZA THOR DISTAL 38X97 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819283 IMPLANTS ZA THOR DISTAL 40X147 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819291 IMPLANTS ZA THOR DISTAL 40X197 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819309 IMPLANTS ZA THOR DISTAL 42X152 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819317 IMPLANTS ZA THOR DISTAL 42X204 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819325 IMPLANTS ZA THOR DISTAL 44X157 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819333 IMPLANTS ZA THOR DISTAL 44X211 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819341 IMPLANTS ZA THOR DISTAL 46X157 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819473 IMPLANTS ZA THOR PROX TAP 30X26X108 GRF EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819481 IMPLANTS ZA THOR PROX TAP 32X28X178 GRF EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819499 IMPLANTS ZA THOR PROX TAP 32X28X210 GRF EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819507 IMPLANTS ZA THOR PROX TAP 34X30X209 GRF EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819515 IMPLANTS ZA THOR PROX TAP 36X32X209 GRF EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819523 IMPLANTS ZA THOR PROX TAP 40X36X217 GRF EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819531 IMPLANTS ZA THOR PROX TAP 42X38X173 GRF EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819549 IMPLANTS ZA THOR PROX TAP 42X38X225 GRF EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819556 IMPLANTS ZA THOR PROX TAP 44X40X233 GRF EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819358 IMPLANTS ZA THOR PROXIMAL 24X105 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819366 IMPLANTS ZA THOR PROXIMAL 28X155 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819374 IMPLANTS ZA THOR PROXIMAL 28X201 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819382 IMPLANTS ZA THOR PROXIMAL 30X201 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819390 IMPLANTS ZA THOR PROXIMAL 32X155 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819408 IMPLANTS ZA THOR PROXIMAL 32X201 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819416 IMPLANTS ZA THOR PROXIMAL 36X161 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819424 IMPLANTS ZA THOR PROXIMAL 36X209 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819432 IMPLANTS ZA THOR PROXIMAL 38X217 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819440 IMPLANTS ZA THOR PROXIMAL 42X225 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819457 IMPLANTS ZA THOR PROXIMAL 44X125 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27819465 IMPLANTS ZA THOR PROXIMAL 46X233 GRAFT EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 26000190 INFUSION THERAPY CASIRIVI AND IMDEVI INFUSION EACH M0243 "$1,170.00 " 260 $819.00 $585.00 $936.00 65% 80% 50% 50% 65% 65% 65% 26000000 INFUSION THERAPY IV INFS THPY FLD INTL 31MN-1HR EACH 96360 $530.00 260 $371.00 $265.00 $424.00 65% 80% 50% 50% 65% 65% 65% 26000018 INFUSION THERAPY IV INFUS THERAPY/DX >8 HR IMPL EACH C8957 $838.00 260 $586.60 $419.00 $670.40 65% 80% 50% 50% 65% 65% 65% 26000026 INFUSION THERAPY IV INFUS THPY FLUID ADDL HR EACH 96361 $118.00 260 $82.60 $59.00 $94.40 65% 80% 50% 50% 65% 65% 65% 26000059 INFUSION THERAPY IV INFUS THPYPRO//DX CONCURREN EACH 96368 $99.00 260 $69.30 $49.50 $79.20 65% 80% 50% 50% 65% 65% 65% 26000067 INFUSION THERAPY IV INFUS THPYPROPH//DX ADDL HR EACH 96366 $118.00 260 $82.60 $59.00 $94.40 65% 80% 50% 50% 65% 65% 65% 26000075 INFUSION THERAPY IV INFUS THPYPROPH//DX INTL UP EACH 96365 $530.00 260 $371.00 $265.00 $424.00 65% 80% 50% 50% 65% 65% 65% 26000083 INFUSION THERAPY NJECT TX/PROPH/DX UNLSTD PROC EACH 96379 $118.00 510 $82.60 $59.00 $94.40 65% 80% 50% 50% 65% Non Payable Non Payable 26000109 INFUSION THERAPY SC INFUS THPYPROPH//DX ADD HR EACH 96370 $118.00 260 $82.60 $59.00 $94.40 65% 80% 50% 50% 65% 65% 65% 26000117 INFUSION THERAPY SC INFUS THPYPROPH//DX ADD PUM EACH 96371 $175.00 260 $122.50 $87.50 $140.00 65% 80% 50% 50% 65% 65% 65% 26000125 INFUSION THERAPY SC INFUS THPYPROPH//DX INTL UP EACH 96369 $530.00 260 $371.00 $265.00 $424.00 65% 80% 50% 50% 65% 65% 65% 26000133 INFUSION THERAPY THERAP/PRO/DX INJ SQ/IM EACH 96372 $175.00 260 $122.50 $87.50 $140.00 65% 80% 50% 50% 65% 65% 65% 26000141 INFUSION THERAPY THERAPYPRO//DX IV PUSH ADDL EACH 96375 $118.00 260 $82.60 $59.00 $94.40 65% 80% 50% 50% 65% 65% 65% 26000158 INFUSION THERAPY THERAPYPRO//DX IV PUSH INITIAL EACH 96374 $530.00 260 $371.00 $265.00 $424.00 65% 80% 50% 50% 65% 65% 65% 26000166 INFUSION THERAPY THERAPYPRO//DX IV PUSH SAME EACH 96376 $99.00 260 $69.30 $49.50 $79.20 65% 80% 50% 50% 65% 65% 65% 26000216 INFUSION THERAPY TRANSFUSE BLOOD/COMP EACH 36430 "$1,074.00 " 391 $751.80 $537.00 $859.20 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 26000034 INFUSION THERAPY TX/PROPH/DG ADDL SEQ IV INF EACH 96367 $175.00 260 $122.50 $87.50 $140.00 65% 80% 50% 50% 65% 65% 65% 72001308 L&D AMNIOCENTESIS$ DIAGNOSTIC EACH 59000 "$1,988.00 " 510 "$1,391.60 " $994.00 "$1,590.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 72001373 L&D "AMNIOINFUSION - (W/US),72 " EACH 59070 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 72001332 L&D CVS-CHORIONIC VILLUS SAMPLING EACH 59015 "$1,988.00 " 510 "$1,391.60 " $994.00 "$1,590.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 72001415 L&D D & C AFTER DELIVERY EACH 59160 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 72001464 L&D DEL OF PLACENTA-SEPARATE PROC EACH 59414 "$7,730.00 " 720 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% of Billed Charges 80% of Billed Charges $264/visit $240/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72000524 L&D DELIVERY NEWBORN RESUSCITATION EACH 99465 "$1,610.00 " 722 "$1,127.00 " $805.00 "$1,288.00 " 65% of Billed Charges 80% of Billed Charges $264/visit $240/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72000474 L&D DELIVERY VAGINAL COMPLEX EACH "$4,594.00 " 722 "$3,215.80 " "$2,297.00 " "$3,675.20 " 65% of Billed Charges 80% of Billed Charges $264/visit $240/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72001456 L&D EXTERNAL CEPHALIC VERSION EACH 59412 "$7,730.00 " 720 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% of Billed Charges 80% of Billed Charges $264/visit $240/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72001399 L&D "FETAL FLUID DRAINAGE (W/US),72" EACH 59074 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 72001365 L&D FETAL SCALP BLOOD SAMPLING EACH 59030 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 72001423 L&D INSERT CERVICAL DILATOR EACH 59200 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 72000508 L&D LABOR COMPLEX < 12 HOURS EACH "$1,671.00 " 721 "$1,169.70 " $835.50 "$1,336.80 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72000516 L&D LABOR COMPLEX > 12 HOURS EACH "$2,228.00 " 721 "$1,559.60 " "$1,114.00 " "$1,782.40 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72000482 L&D LABOR UNCOMPLICATED < 12HOURS EACH $557.00 721 $389.90 $278.50 $445.60 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72000490 L&D LABOR UNCOMPLICATED > 12HOURS EACH "$1,114.00 " 721 $779.80 $557.00 $891.20 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72000185 L&D NORMAL DELIVERY EACH "$3,594.00 " 722 "$2,515.80 " "$1,797.00 " "$2,875.20 " 65% of Billed Charges 80% of Billed Charges $264/visit $240/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72000532 L&D OB/GYNE SURGERY BASIC LEVEL 1 FIRST HOUR EACH "$3,608.00 " 360 "$2,525.60 " "$1,804.00 " "$2,886.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 72000573 L&D OB/GYNE SURGERY COMPL LEVEL 3 EA ADDL 30 MIN EACH "$7,570.00 " "$5,299.00 " "$3,785.00 " "$6,056.00 " 65% of Billed Charges Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 72000573 L&D OB/GYNE SURGERY COMPL LEVEL 3 FIRST HUR EACH "$7,570.00 " 360 "$5,299.00 " "$3,785.00 " "$6,056.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 72000557 L&D OB/GYNE SURGERY INTER LEVEL 2 FIRST HOUR EACH "$5,589.00 " 360 "$3,912.30 " "$2,794.50 " "$4,471.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 72001530 L&D REMOVE CERCLAGE SUTURE EACH 59871 "$7,730.00 " 510 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 72000425 L&D TEST NON STRESS FETAL EACH 59025 $493.00 920 $345.10 $246.50 $394.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 72000433 L&D TEST STRESS FETAL EACH 59020 $493.00 920 $345.10 $246.50 $394.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 72001381 L&D UMBILICAL CORD OCCL (W/US) EACH 59072 $794.00 510 $555.80 $397.00 $635.20 65% 80% 50% 50% 65% Non Payable Non Payable 72001449 L&D VAGINAL DELIVERY EACH 59409 "$7,730.00 " 720 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% of Billed Charges 80% of Billed Charges $264/visit $240/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 72001472 L&D VBAC DELIVERY EACH 59612 "$7,730.00 " 720 "$5,411.00 " "$3,865.00 " "$6,184.00 " 65% of Billed Charges 80% of Billed Charges $264/visit $240/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000005 LAB/BLOOD BANK APHERESIS EXTRACORP SELECT EACH 36516 "$11,443.00 " 510 "$8,010.10 " "$5,721.50 " "$9,154.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 39000013 LAB/BLOOD BANK APHERESIS PLASMA PHERESIS EACH 36514 "$3,794.00 " 510 "$2,655.80 " "$1,897.00 " "$3,035.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 39000021 LAB/BLOOD BANK APHERESIS PLATELETS EACH 36513 "$1,074.00 " 510 $751.80 $537.00 $859.20 65% 80% 50% 50% 65% Non Payable Non Payable 39000047 LAB/BLOOD BANK APHERESIS THERAPEUTIC WBC EACH 36511 "$3,794.00 " 510 "$2,655.80 " "$1,897.00 " "$3,035.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 39000054 LAB/BLOOD BANK BLOOD PREP/FREEZE/THAW EACH 86932 $100.00 302 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges $17.92 $17.92 $86.87 65% of Billed Charges 65% of Billed Charges 39000062 LAB/BLOOD BANK BLOOD PROCESSING AUTOLOGOUS EACH 86890 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000070 LAB/BLOOD BANK BLOOD PRODUCT IRRADIATION EACH 86945 $100.00 300 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% 65% 65% 39000088 LAB/BLOOD BANK BLOOD PRODUCT POOL EACH 86965 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000096 LAB/BLOOD BANK BLOOD PRODUCT VOLUME REDUCTION EACH 86960 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000104 LAB/BLOOD BANK BLOOD SALVAGE AUTOLOGOUS INTRA EACH 86891 "$2,127.00 " 300 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% 80% 50% 50% 65% 65% 65% 39000112 LAB/BLOOD BANK BLOOD SPLIT UNIT SPECIFY AMT EACH P9011 $387.00 390 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000120 LAB/BLOOD BANK BLOOD THAWING EACH 86931 $423.00 302 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $17.92 $17.92 $76.84 65% of Billed Charges 65% of Billed Charges 39000609 LAB/BLOOD BANK BLOOD TYPE ANTIGEN DONOR EA EACH 86902 $889.00 300 $622.30 $444.50 $711.20 65% 80% 50% 50% 65% 65% 65% 39000138 LAB/BLOOD BANK BLOOD TYPING ABO EACH 86900 $316.00 300 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% 65% 65% 39000146 LAB/BLOOD BANK BLOOD TYPING PATERNITY ABO/RH/ EACH 86910 $49.00 300 $34.30 $24.50 $39.20 65% 80% 50% 50% 65% 65% 65% 39000153 LAB/BLOOD BANK BLOOD TYPING PATERNITY EA AD EACH 86911 $49.00 300 $34.30 $24.50 $39.20 65% 80% 50% 50% 65% 65% 65% 39000161 LAB/BLOOD BANK BLOOD TYPING RH (D) EACH 86901 $100.00 300 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% 65% 65% 39000179 LAB/BLOOD BANK BLOOD TYPING RH PHENOTYPE EACH 86906 $100.00 300 $70.00 $50.00 $80.00 65% 80% 50% 50% 65% 65% 65% 39000187 LAB/BLOOD BANK COMPAT TEST ELECTRONIC EACH 86923 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000195 LAB/BLOOD BANK COOMBS DIRECT EACH 86880 $152.00 302 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $2.77 Non Payable $4.37 65% of Billed Charges 65% of Billed Charges 39000203 LAB/BLOOD BANK COOMBS INDIRECT QL EACH 86885 $423.00 302 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $2.95 Non Payable $4.63 65% of Billed Charges 65% of Billed Charges 39000211 LAB/BLOOD BANK COOMBS INDIRECT TITER EACH 86886 $423.00 302 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $2.67 Non Payable $4.20 65% of Billed Charges 65% of Billed Charges 39000229 LAB/BLOOD BANK CROSSMATCH ANTIGLOBULIN EACH 86922 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000237 LAB/BLOOD BANK CROSSMATCH IMMEDIATE SPIN EACH 86920 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000245 LAB/BLOOD BANK CROSSMATCH INCUBATION EACH 86921 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000252 LAB/BLOOD BANK CRYOPRECIPITATE EA UNIT EACH P9012 $156.00 390 $109.20 $78.00 $124.80 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000260 LAB/BLOOD BANK FFP EA EACH P9017 $208.00 390 $145.60 $104.00 $166.40 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000278 LAB/BLOOD BANK FRESH FROZEN PLASMA THAWING EACH 86927 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000286 LAB/BLOOD BANK HEMOLYSIN AGGLUTIN AUTO SCREEN EACH 86940 $22.00 300 $15.40 $11.00 $17.60 65% 80% 50% 50% 65% 65% 65% 39000294 LAB/BLOOD BANK HEMOLYSINS AGGLUTININ INCUBATE EACH 86941 $31.00 300 $21.70 $15.50 $24.80 65% 80% 50% 50% 65% 65% 65% 39000302 LAB/BLOOD BANK LEUKOCYTE TRANSFUSION EACH 86950 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000310 LAB/BLOOD BANK PLASMA PLATELET RICH EA EACH P9020 "$1,425.00 " 390 $997.50 $712.50 "$1,140.00 " 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000328 LAB/BLOOD BANK PLASMA POOL MULTI DONOR SD FRZ EACH P9023 $157.00 390 $109.90 $78.50 $125.60 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000658 LAB/BLOOD BANK "PLASMA, FRZ BETWEEN 8-24HOUR " EACH P9059 $189.00 390 $132.30 $94.50 $151.20 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000336 LAB/BLOOD BANK PLATELET CONC L/R EA EACH P9031 $340.00 390 $238.00 $170.00 $272.00 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000625 LAB/BLOOD BANK PLATELETS LEUKOREDUCED IRRAD EACH P9033 $599.00 390 $419.30 $299.50 $479.20 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000344 LAB/BLOOD BANK PLATELETS PHER EA EACH P9034 $836.00 390 $585.20 $418.00 $668.80 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000351 LAB/BLOOD BANK PLATELETS PHER IRR EA EACH P9036 "$1,454.00 " 390 "$1,017.80 " $727.00 "$1,163.20 " 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000369 LAB/BLOOD BANK PLATELETS PHER L/R EA EACH P9035 "$1,226.00 " 390 $858.20 $613.00 $980.80 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000377 LAB/BLOOD BANK PLATELETS PHER L/R IRR EA EACH P9037 "$1,746.00 " 390 "$1,222.20 " $873.00 "$1,396.80 " 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000708 LAB/BLOOD BANK PLATELETS PHERESIS PATH REDU EACH P9073 "$1,431.00 " 390 "$1,001.70 " $715.50 "$1,144.80 " 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000385 LAB/BLOOD BANK PLATELETS SINGLE DONOR EA EACH P9019 $169.00 390 $118.30 $84.50 $135.20 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000617 LAB/BLOOD BANK "PLATELETS, IRRADIATED, EA UNIT" EACH P9032 $347.00 390 $242.90 $173.50 $277.60 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000393 LAB/BLOOD BANK RBC AB IDENTIFICATION PANEL EACH 86870 $889.00 302 $622.30 $444.50 $711.20 65% of Billed Charges 80% of Billed Charges $9.06 Non Payable $37.97 65% of Billed Charges 65% of Billed Charges 39000401 LAB/BLOOD BANK RBC AG SCREEN PATIENT SERUM EACH 86904 $152.00 300 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% 65% 65% 39000427 LAB/BLOOD BANK RBC AG TYPING NON ABO/RH EACH 86905 $889.00 300 $622.30 $444.50 $711.20 65% 80% 50% 50% 65% 65% 65% 39000435 LAB/BLOOD BANK RBC ANTIBODY ELUTION EACH 86860 $423.00 302 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $9.06 Non Payable $27.64 65% of Billed Charges 65% of Billed Charges 39000443 LAB/BLOOD BANK RBC ANTIBODY SCREEN EACH 86850 $134.00 302 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $5.33 Non Payable $7.91 65% of Billed Charges 65% of Billed Charges 39000633 LAB/BLOOD BANK "RBC IRRADIATED, EACH UNIT " EACH P9038 $563.00 390 $394.10 $281.50 $450.40 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000450 LAB/BLOOD BANK RBC PRETREAT ABSOR EACH 86978 $152.00 302 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $9.06 $9.06 $30.68 65% of Billed Charges 65% of Billed Charges 39000468 LAB/BLOOD BANK RBC PRETREAT CHEMICAL EACH 86970 $152.00 300 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% 65% 65% 39000476 LAB/BLOOD BANK RBC PRETREAT DENSITY SEPARATE EACH 86972 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000484 LAB/BLOOD BANK RBC PRETREAT ENZYME EACH 86971 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000492 LAB/BLOOD BANK RBC PRETREAT SERUM DILUTION EACH 86976 $74.00 302 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $5.33 $5.33 $30.68 65% of Billed Charges 65% of Billed Charges 39000500 LAB/BLOOD BANK RBC PRETREAT SERUM INCUBATION EACH 86975 $986.00 302 $690.20 $493.00 $788.80 65% of Billed Charges 80% of Billed Charges $9.06 $9.06 $27.64 65% of Billed Charges 65% of Billed Charges 39000518 LAB/BLOOD BANK RBC PRETREAT SERUM INHIBIT EACH 86977 $423.00 302 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $17.92 $17.92 $30.68 65% of Billed Charges 65% of Billed Charges 39000641 LAB/BLOOD BANK "RBC, L/R, CMV-NEG, IRRAD " EACH P9058 $628.00 390 $439.60 $314.00 $502.40 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000526 LAB/BLOOD BANK RED CELLS DEGLY EA EACH P9039 $808.00 390 $565.60 $404.00 $646.40 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000534 LAB/BLOOD BANK RED CELLS L/R EA EACH P9016 $470.00 390 $329.00 $235.00 $376.00 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000591 LAB/BLOOD BANK RED CELLS L/R IRR EA EACH P9040 $656.00 390 $459.20 $328.00 $524.80 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000542 LAB/BLOOD BANK RED CELLS PACKED EA EACH P9021 $355.00 390 $248.50 $177.50 $284.00 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000559 LAB/BLOOD BANK RED CELLS WASHED EA EACH P9022 "$1,031.00 " 390 $721.70 $515.50 $824.80 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 39000674 LAB/BLOOD BANK RHOGAM 300 MCG EACH $199.00 250 $139.30 $99.50 $159.20 65% 80% 50% 50% 65% 65% 65% 39000682 LAB/BLOOD BANK RHOGAM MINI DOSE 50 MCG EACH $80.00 250 $56.00 $40.00 $64.00 65% 80% 50% 50% 65% 65% 65% 39000567 LAB/BLOOD BANK SPLITTING BLOOD PRODUCT EA EACH 86985 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 39000575 LAB/BLOOD BANK TRANSFUSION UNLSTD PROC EACH 86999 $74.00 300 $51.80 $37.00 $59.20 65% 80% 50% 50% 65% 65% 65% 39000583 LAB/BLOOD BANK WHOLE BLOOD EA DIR EACH P9010 $528.00 390 $369.60 $264.00 $422.40 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 30514962 LAB/GENERAL ABL KINASE DOM MUTATION CML EACH 81170 $750.00 310 $525.00 $375.00 $600.00 65% of Billed Charges 80% of Billed Charges $118.62 $118.62 $243.00 65% of Billed Charges 65% of Billed Charges 30500037 LAB/GENERAL ACETONE KETONES SERUM QL EACH 82009 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.33 $2.33 $3.66 65% of Billed Charges 65% of Billed Charges 30500052 LAB/GENERAL ACETYLCHOLINESTERASE EACH 82013 $31.00 301 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $5.76 $5.76 $9.95 65% of Billed Charges 65% of Billed Charges 30500060 LAB/GENERAL ACTH STIM PANEL ADRENAL EACH 80400 $82.00 301 $57.40 $41.00 $65.60 65% of Billed Charges 80% of Billed Charges $16.81 $16.81 $26.42 65% of Billed Charges 65% of Billed Charges 30500078 LAB/GENERAL ACTINCES ANTIBODY EACH 86602 $26.00 302 $18.20 $13.00 $20.80 65% of Billed Charges 80% of Billed Charges $5.25 $5.25 $8.25 65% of Billed Charges 65% of Billed Charges 30500086 LAB/GENERAL ACUTE HEPATITIS PANEL EACH 80074 $120.00 301 $84.00 $60.00 $96.00 65% of Billed Charges 80% of Billed Charges $24.56 $24.56 $38.58 65% of Billed Charges 65% of Billed Charges 30511588 LAB/GENERAL "ACYLCARNITINES, EACH SPECIMEN " EACH 82017 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.70 $8.70 $13.66 65% of Billed Charges 65% of Billed Charges 30515126 LAB/GENERAL ADALIMUMAB EACH 80145 $97.00 301 $67.90 $48.50 $77.60 65% of Billed Charges 80% of Billed Charges $13.89 $13.89 $31.24 65% of Billed Charges 65% of Billed Charges 30515134 LAB/GENERAL ADAMTS13 ACTIVITY W/REFLEX EACH 85397 $78.00 305 $54.60 $39.00 $62.40 65% of Billed Charges 80% of Billed Charges $11.83 $11.83 $25.00 65% of Billed Charges 65% of Billed Charges 30500094 LAB/GENERAL ADENOSINE CYCLIC (AMP) EACH 82030 $65.00 301 $45.50 $32.50 $52.00 65% of Billed Charges 80% of Billed Charges $13.30 $13.30 $20.90 65% of Billed Charges 65% of Billed Charges 30500128 LAB/GENERAL AGGLUTININS FEBRILE EA ANTIGEN EACH 86000 $18.00 302 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.60 $3.60 $5.65 65% of Billed Charges 65% of Billed Charges 30500136 LAB/GENERAL AGGLUTININS FEBRILE TULAREMIA EACH 86000 $18.00 302 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.60 $3.60 $5.65 65% of Billed Charges 65% of Billed Charges 30500144 LAB/GENERAL AGGLUTININS FEBRILE TYPHUS EACH 86000 $18.00 302 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.60 $3.60 $5.65 65% of Billed Charges 65% of Billed Charges 30500151 LAB/GENERAL ALBUMIN BODY FLUID EACH 82042 $20.00 301 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $2.67 $2.67 $6.30 65% of Billed Charges 65% of Billed Charges 30512966 LAB/GENERAL ALBUMIN SERUM EACH 82040 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.55 $2.55 $4.01 65% of Billed Charges 65% of Billed Charges 30500193 LAB/GENERAL ALCOHOL (ETOH) BREATH EACH 82075 $75.00 301 $52.50 $37.50 $60.00 65% of Billed Charges 80% of Billed Charges $6.21 $6.21 $0.01 65% of Billed Charges 65% of Billed Charges 30500227 LAB/GENERAL ALDOSTERONE EACH 82088 $102.00 301 $71.40 $51.00 $81.60 65% of Billed Charges 80% of Billed Charges $21.01 $21.01 $33.01 65% of Billed Charges 65% of Billed Charges 30500235 LAB/GENERAL ALDOSTERONE SUPPRESS PANEL EACH 80408 $314.00 301 $219.80 $157.00 $251.20 65% of Billed Charges 80% of Billed Charges $64.71 $64.71 $101.66 65% of Billed Charges 65% of Billed Charges 30500250 LAB/GENERAL ALKALOIDS URINE QN EACH 80323 $392.00 301 $274.40 $196.00 $313.60 65% of Billed Charges 80% of Billed Charges $14.71 $14.71 $0.01 65% of Billed Charges 65% of Billed Charges 30511174 LAB/GENERAL ALLERGEN IGE QN SQ 1ST EACH 86003 $14.00 300 $9.80 $7.00 $11.20 65% 80% 50% Non Payable 65% 65% 65% 30500268 LAB/GENERAL ALPHA 2 ANTIPLASMIN EACH 85410 $20.00 305 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $3.98 $3.98 $6.25 65% of Billed Charges 65% of Billed Charges 30500276 LAB/GENERAL ALPHA FETOPROTEIN AMNIOTIC EACH 82106 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.65 $8.65 $13.77 65% of Billed Charges 65% of Billed Charges 30512974 LAB/GENERAL ALPHA FETOPROTEIN SERUM EACH 82105 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.65 $8.65 $13.58 65% of Billed Charges 65% of Billed Charges 30500292 LAB/GENERAL ALPHA-1 ANTITRYPSIN PHENOTYPE EACH 82104 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.46 $7.46 $11.71 65% of Billed Charges 65% of Billed Charges 30515472 LAB/GENERAL ALPHA-1-ANTITRYPSIN QN EACH 81332 $110.00 310 $77.00 $55.00 $88.00 65% of Billed Charges 80% of Billed Charges $21.44 $21.44 $35.36 65% of Billed Charges 65% of Billed Charges 30500318 LAB/GENERAL ALT/SGPT EACH 84460 $14.00 301 $9.80 $7.00 $11.20 65% of Billed Charges 80% of Billed Charges $2.73 $2.73 $4.29 65% of Billed Charges 65% of Billed Charges 30500334 LAB/GENERAL ALUMINUM SERUM EACH 82108 $64.00 301 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $13.14 $13.14 $20.64 65% of Billed Charges 65% of Billed Charges 30500342 LAB/GENERAL AMIKACIN PEAK EACH 80150 $38.00 301 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.77 $7.77 $12.21 65% of Billed Charges 65% of Billed Charges 30500375 LAB/GENERAL AMINO ACIDS QL MULTIPLE PLASMA EACH 82128 $35.00 301 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.15 $7.15 $11.23 65% of Billed Charges 65% of Billed Charges 30500391 LAB/GENERAL AMINO ACIDS QN SGL PLASMA EACH 82131 $58.00 301 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges $8.70 $8.70 $18.61 65% of Billed Charges 65% of Billed Charges 30500417 LAB/GENERAL AMINOLEVULINIC ACID (ALA) EACH 82135 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.49 $8.49 $13.32 65% of Billed Charges 65% of Billed Charges 30500433 LAB/GENERAL AMMONIA EACH 82140 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.51 $7.51 $11.80 65% of Billed Charges 65% of Billed Charges 30500441 LAB/GENERAL AMNIOTIC FLUID SCAN EACH 82143 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $3.54 $3.54 $7.57 65% of Billed Charges 65% of Billed Charges 30500466 LAB/GENERAL AMYLASE BODY FLUID EACH 82150 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.25 65% of Billed Charges 65% of Billed Charges 30500508 LAB/GENERAL ANDROSTERONE EACH 82160 $64.00 301 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $12.90 $12.90 $20.70 65% of Billed Charges 65% of Billed Charges 30500516 LAB/GENERAL ANGIOTENSIN I ENZYME (ACE) EACH 82164 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.53 $7.53 $11.83 65% of Billed Charges 65% of Billed Charges 30500524 LAB/GENERAL ANGIOTENSIN II EACH 82163 $52.00 301 $36.40 $26.00 $41.60 65% of Billed Charges 80% of Billed Charges $10.58 $10.58 $16.62 65% of Billed Charges 65% of Billed Charges 30512172 LAB/GENERAL ANTIBODY CONSULTATION (ABCON) EACH 86077 $74.00 305 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $44.78 65% of Billed Charges 65% of Billed Charges 30512198 LAB/GENERAL "ANTIBODY; FUNGUS, NOS (FIRST) " EACH 86671 $31.00 300 $21.70 $15.50 $24.80 65% 80% 50% 50% 65% 65% 65% 30500540 LAB/GENERAL ANTINUCLEAR ANTIBODY SCREEN EACH 86038 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.24 $6.24 $9.79 65% of Billed Charges 65% of Billed Charges 30500557 LAB/GENERAL ANTINUCLEAR ANTIBODY TITER EACH 86039 $28.00 302 $19.60 $14.00 $22.40 65% of Billed Charges 80% of Billed Charges $5.76 $5.76 $9.04 65% of Billed Charges 65% of Billed Charges 30500581 LAB/GENERAL ANTITHROMBIN III ANTIGEN EACH 85301 $28.00 305 $19.60 $14.00 $22.40 65% of Billed Charges 80% of Billed Charges $5.58 $5.58 $8.76 65% of Billed Charges 65% of Billed Charges 30512339 LAB/GENERAL APC GENE DUP/DELETE VARIANTS EACH 81203 $500.00 310 $350.00 $250.00 $400.00 65% of Billed Charges 80% of Billed Charges $72.00 $72.00 $162.00 65% of Billed Charges 65% of Billed Charges 30512321 LAB/GENERAL APC GENE FULL SEQUENCE EACH 81201 "$1,950.00 " 310 "$1,365.00 " $975.00 "$1,560.00 " 65% of Billed Charges 80% of Billed Charges $280.80 $280.80 $631.80 65% of Billed Charges 65% of Billed Charges 30500599 LAB/GENERAL APOLIPOPROTEIN EACH 82172 $53.00 301 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $7.99 $7.99 $17.08 65% of Billed Charges 65% of Billed Charges 30500615 LAB/GENERAL ARSENIC URINE EACH 82175 $48.00 301 $33.60 $24.00 $38.40 65% of Billed Charges 80% of Billed Charges $9.78 $9.78 $15.37 65% of Billed Charges 65% of Billed Charges 30500623 LAB/GENERAL ASPERGILLUS AGENT ENZYME INFEC EACH 87305 $30.00 302 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $9.70 65% of Billed Charges 65% of Billed Charges 30511422 LAB/GENERAL ASPERGILLUS ANTIBODY EACH 86606 $38.00 302 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.76 $7.76 $12.19 65% of Billed Charges 65% of Billed Charges 30500649 LAB/GENERAL ASSAY OF LIPOPROTEIN A EACH 83695 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $6.67 $6.67 $11.60 65% of Billed Charges 65% of Billed Charges 30500656 LAB/GENERAL ASSTD OOCYTE FERT 10 OR LESS EACH 89280 "$2,127.00 " 309 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $622.96 65% of Billed Charges 65% of Billed Charges 30500664 LAB/GENERAL ASSTD OOCYTE FERT MORE THAN 10 EACH 89281 $423.00 309 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $755.68 65% of Billed Charges 65% of Billed Charges 30500672 LAB/GENERAL AST/SGOT EACH 84450 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.67 $2.67 $4.20 65% of Billed Charges 65% of Billed Charges 30500680 LAB/GENERAL ATOMIC ABSOR THALLIUM EACH 82190 $40.00 301 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $7.69 $7.69 $12.88 65% of Billed Charges 65% of Billed Charges 30500698 LAB/GENERAL B CELLS TOTAL EACH 86355 $95.00 302 $66.50 $47.50 $76.00 65% of Billed Charges 80% of Billed Charges $19.45 $19.45 $30.56 65% of Billed Charges 65% of Billed Charges 30500706 LAB/GENERAL BACTERICIDAL TITER (SCHLICTER) EACH 87197 $38.00 300 $26.60 $19.00 $30.40 65% 80% 50% 50% 65% 65% 65% 30500722 LAB/GENERAL BARTONELLA ANTIBODY EACH 86611 $26.00 302 $18.20 $13.00 $20.80 65% of Billed Charges 80% of Billed Charges $5.25 $5.25 $8.25 65% of Billed Charges 65% of Billed Charges 30511091 LAB/GENERAL BASIC METAB PANEL (CAL-ION) EACH 80047 $35.00 301 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $4.36 $4.36 $11.12 65% of Billed Charges 65% of Billed Charges 30500730 LAB/GENERAL BASIC METAB PANEL (CAL-TOTAL) EACH 80048 $22.00 301 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges $4.36 $4.36 $6.85 65% of Billed Charges 65% of Billed Charges 30500748 LAB/GENERAL BENZODIAZEPINES EACH 80346 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $9.70 $9.70 $0.01 65% of Billed Charges 65% of Billed Charges 30500771 LAB/GENERAL BETA-2 MICROGLOBULIN URINE EACH 82232 $41.00 301 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $8.34 $8.34 $13.11 65% of Billed Charges 65% of Billed Charges 30500789 LAB/GENERAL BILE ACIDS EACH 82239 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.83 $8.83 $13.87 65% of Billed Charges 65% of Billed Charges 30500797 LAB/GENERAL BILE ACIDS CHOLYLGLYCINE EACH 82240 $67.00 301 $46.90 $33.50 $53.60 65% of Billed Charges 80% of Billed Charges $13.71 $13.71 $21.53 65% of Billed Charges 65% of Billed Charges 30500805 LAB/GENERAL BILIRUBIN DIRECT EACH 82248 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.59 $2.59 $4.07 65% of Billed Charges 65% of Billed Charges 30500813 LAB/GENERAL BILIRUBIN FECES QL EACH 82252 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.34 $2.34 $3.69 65% of Billed Charges 65% of Billed Charges 30500821 LAB/GENERAL BILIRUBIN TOTAL BODY FLUID EACH 82247 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.59 $2.59 $4.07 65% of Billed Charges 65% of Billed Charges 30500854 LAB/GENERAL BIOTINIDASE EA SPECIMEN EACH 82261 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.70 $8.70 $13.66 65% of Billed Charges 65% of Billed Charges 30500862 LAB/GENERAL BLASTOMYCES ANTIBODY EACH 86612 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.66 $6.66 $10.45 65% of Billed Charges 65% of Billed Charges 30500870 LAB/GENERAL BLEEDING TIME EACH 85002 $13.00 305 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.32 $2.32 $3.90 65% of Billed Charges 65% of Billed Charges 30500888 LAB/GENERAL BLOOD COUNT AUTO DIFF WBC EACH 85004 $17.00 305 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.24 65% of Billed Charges 65% of Billed Charges 30500896 LAB/GENERAL BLOOD COUNT LEUKOCYTE AUTO EACH 85048 $7.00 305 $4.90 $3.50 $5.60 65% of Billed Charges 80% of Billed Charges $1.31 $1.31 $2.06 65% of Billed Charges 65% of Billed Charges 30500904 LAB/GENERAL BLOOD COUNT MANUAL DIFF BUFFY EACH 85009 $13.00 305 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $1.92 $1.92 $4.11 65% of Billed Charges 65% of Billed Charges 30500912 LAB/GENERAL BLOOD COUNT MANUAL DIFF WBC EACH 85007 $10.00 305 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $1.77 $1.77 $3.08 65% of Billed Charges 65% of Billed Charges 30500920 LAB/GENERAL BLOOD COUNT PLATELET AUTO EACH 85049 $12.00 305 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.30 $2.30 $3.63 65% of Billed Charges 65% of Billed Charges 30500938 LAB/GENERAL BLOOD COUNT RBC AUTO EACH 85041 $8.00 305 $5.60 $4.00 $6.40 65% of Billed Charges 80% of Billed Charges $1.55 $1.55 $2.45 65% of Billed Charges 65% of Billed Charges 30500946 LAB/GENERAL BLOOD COUNT RETICULOCYTE AUTO EACH 85045 $10.00 305 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $2.07 $2.07 $3.23 65% of Billed Charges 65% of Billed Charges 30500953 LAB/GENERAL BLOOD COUNT RETICULOCYTE MAN EACH 85044 $11.00 305 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $2.22 $2.22 $3.49 65% of Billed Charges 65% of Billed Charges 30500961 LAB/GENERAL BLOOD GAS O2 SAT ONLY EACH 82810 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $4.50 $4.50 $7.91 65% of Billed Charges 65% of Billed Charges 30500979 LAB/GENERAL BLOOD GAS PH EACH 82800 $28.00 301 $19.60 $14.00 $22.40 65% of Billed Charges 80% of Billed Charges $4.37 $4.37 $8.91 65% of Billed Charges 65% of Billed Charges 30500987 LAB/GENERAL BLOOD GAS PH PO2 &/OR PCO2 EACH 82803 $66.00 301 $46.20 $33.00 $52.80 65% of Billed Charges 80% of Billed Charges $9.98 $9.98 $21.12 65% of Billed Charges 65% of Billed Charges 30500995 LAB/GENERAL BLOOD GAS W/O2 SAT EACH 82805 $197.00 301 $137.90 $98.50 $157.60 65% of Billed Charges 80% of Billed Charges $14.63 $14.63 $63.80 65% of Billed Charges 65% of Billed Charges 30501019 LAB/GENERAL BLOOD SMEAR W/O DIFFERENTIAL EACH 85008 $9.00 305 $6.30 $4.50 $7.20 65% of Billed Charges 80% of Billed Charges $1.77 $1.77 $2.78 65% of Billed Charges 65% of Billed Charges 30512669 LAB/GENERAL "BLOOD, OCCULT FECES 1-3 (IFOB)" EACH 82274 $46.00 301 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $8.20 $8.20 $12.90 65% of Billed Charges 65% of Billed Charges 30501027 LAB/GENERAL BONE MARROW SMEAR INTERP EACH 85097 "$2,127.00 " 305 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $43.56 65% of Billed Charges 65% of Billed Charges 30501035 LAB/GENERAL BORDETELLA ANTIBODY EACH 86615 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30501043 LAB/GENERAL BORRELIA ANTIBODY EACH 86619 $34.00 302 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.90 $6.90 $10.84 65% of Billed Charges 65% of Billed Charges 30501050 LAB/GENERAL BRADYKININ EACH 82286 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $3.55 $3.55 $4.18 65% of Billed Charges 65% of Billed Charges 30501068 LAB/GENERAL BRUCELLA ANTIBODY EACH 86622 $23.00 302 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $4.60 $4.60 $7.23 65% of Billed Charges 65% of Billed Charges 30501076 LAB/GENERAL BX OOC MORE THAN 5 EMBRYOS EACH 89291 $423.00 309 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $981.42 65% of Billed Charges 65% of Billed Charges 30501084 LAB/GENERAL BX OOCYTE 5 OR LESS EMBRYOS EACH 89290 $423.00 309 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $759.80 65% of Billed Charges 65% of Billed Charges 30501092 LAB/GENERAL CADMIUM BLOOD EACH 82300 $60.00 301 $42.00 $30.00 $48.00 65% of Billed Charges 80% of Billed Charges $11.93 $11.93 $19.15 65% of Billed Charges 65% of Billed Charges 30501126 LAB/GENERAL CALCIUM AFTER CALCIUM INFUSION EACH 82331 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $2.67 $2.67 $10.81 65% of Billed Charges 65% of Billed Charges 30501134 LAB/GENERAL CALCIUM IONIZED EACH 82330 $35.00 301 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.05 $7.05 $11.08 65% of Billed Charges 65% of Billed Charges 30501159 LAB/GENERAL CALCIUM URINE QN TIMED EACH 82340 $16.00 301 $11.20 $8.00 $12.80 65% of Billed Charges 80% of Billed Charges $3.11 $3.11 $4.88 65% of Billed Charges 65% of Billed Charges 30501175 LAB/GENERAL CALCULUS ANLYS QL EACH 82355 $29.00 301 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.97 $5.97 $9.38 65% of Billed Charges 65% of Billed Charges 30501183 LAB/GENERAL CALCULUS ANLYS QN EACH 82360 $33.00 301 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.64 $6.64 $10.42 65% of Billed Charges 65% of Billed Charges 30515175 LAB/GENERAL "CALPROTECTIN, STOOL " EACH 83993 $50.00 301 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $10.12 $10.12 $15.90 65% of Billed Charges 65% of Billed Charges 30501191 LAB/GENERAL CAMPYLOBACTER ANTIBODY EACH 86625 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.77 $6.77 $10.63 65% of Billed Charges 65% of Billed Charges 30501209 LAB/GENERAL CANDIDA ANTIBODY EACH 86628 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.19 $6.19 $9.73 65% of Billed Charges 65% of Billed Charges 30501217 LAB/GENERAL CARBAMAZEPINE (TEGRETOL) TOTAL EACH 80156 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.51 $7.51 $11.80 65% of Billed Charges 65% of Billed Charges 30501225 LAB/GENERAL CARBON DIOXIDE (BICARB) EACH 82374 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.52 $2.52 $3.95 65% of Billed Charges 65% of Billed Charges 30501233 LAB/GENERAL CARBON MONOXIDE (CO-OX) QL EACH 82376 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $3.09 $3.09 $11.40 65% of Billed Charges 65% of Billed Charges 30501241 LAB/GENERAL CARBON MONOXIDE (CO-OX) QN EACH 82375 $31.00 301 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.36 $6.36 $9.98 65% of Billed Charges 65% of Billed Charges 30501258 LAB/GENERAL CARCINOEMBRYONIC AG (CEA) EACH 82378 $48.00 301 $33.60 $24.00 $38.40 65% of Billed Charges 80% of Billed Charges $9.78 $9.78 $15.36 65% of Billed Charges 65% of Billed Charges 30501266 LAB/GENERAL CARDIOLIPIN PHOSPHO AB EA IG EACH 86147 $64.00 302 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $13.12 $13.12 $20.61 65% of Billed Charges 65% of Billed Charges 30501274 LAB/GENERAL CARNITINE TOTAL AND FREE QN EACH 82379 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.70 $8.70 $13.66 65% of Billed Charges 65% of Billed Charges 30501282 LAB/GENERAL CAROTENE EACH 82380 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $4.76 $4.76 $7.47 65% of Billed Charges 65% of Billed Charges 30501324 LAB/GENERAL CATHEPSIN-D EACH 82387 $46.00 301 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $10.73 $10.73 $14.63 65% of Billed Charges 65% of Billed Charges 30501332 LAB/GENERAL CBC AUTO W/AUTO DIF EACH 85025 $20.00 305 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $4.01 $4.01 $6.29 65% of Billed Charges 65% of Billed Charges 30501340 LAB/GENERAL CBC AUTO W/O DIFF EACH 85027 $17.00 305 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.24 65% of Billed Charges 65% of Billed Charges 30501357 LAB/GENERAL CCP ANTIBODY EACH 86200 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.67 $6.67 $10.49 65% of Billed Charges 65% of Billed Charges 30501373 LAB/GENERAL CELL COUNT BODY FLUID W/DIFF EACH 89051 $27.00 309 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $2.84 $2.84 $4.54 65% of Billed Charges 65% of Billed Charges 30501381 LAB/GENERAL CELL COUNT CSF EACH 89050 $23.00 309 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $2.44 $2.44 $3.82 65% of Billed Charges 65% of Billed Charges 30501415 LAB/GENERAL CHEMISTRY UNLSTD PROC EACH 84999 $91.00 301 $63.70 $45.50 $72.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 30501423 LAB/GENERAL CHEMOTAXIS ASSAY EACH 86155 $40.00 302 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $8.24 $8.24 $12.95 65% of Billed Charges 65% of Billed Charges 30501431 LAB/GENERAL CHLAMYDIA ANTIBODY EACH 86631 $30.00 302 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.10 $6.10 $9.57 65% of Billed Charges 65% of Billed Charges 30501456 LAB/GENERAL CHLORAMPHENICOL EACH 82415 $32.00 301 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.53 $6.53 $10.26 65% of Billed Charges 65% of Billed Charges 30501472 LAB/GENERAL CHLORIDE CSF EACH 82438 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.52 $2.52 $4.05 65% of Billed Charges 65% of Billed Charges 30501498 LAB/GENERAL CHLORIDE SERUM EACH 82435 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.37 $2.37 $3.73 65% of Billed Charges 65% of Billed Charges 30501506 LAB/GENERAL CHLORIDE URINE EACH 82436 $15.00 301 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $2.59 $2.59 $4.66 65% of Billed Charges 65% of Billed Charges 30501514 LAB/GENERAL CHLORINATED HYDROCARBON SCREEN EACH 82441 $16.00 301 $11.20 $8.00 $12.80 65% of Billed Charges 80% of Billed Charges $3.10 $3.10 $4.87 65% of Billed Charges 65% of Billed Charges 30501522 LAB/GENERAL CHOLESTEROL BLOOD TOTAL EACH 82465 $11.00 301 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $2.25 $2.25 $3.52 65% of Billed Charges 65% of Billed Charges 30501530 LAB/GENERAL CHOLESTEROL HDL EACH 83718 $21.00 301 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $4.22 $4.22 $6.63 65% of Billed Charges 65% of Billed Charges 30501548 LAB/GENERAL CHOLESTEROL LDL EACH 83721 $27.00 301 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $4.92 $4.92 $8.51 65% of Billed Charges 65% of Billed Charges 30501555 LAB/GENERAL CHOLESTEROL VLDL EACH 83719 $32.00 301 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.00 $6.00 $10.33 65% of Billed Charges 65% of Billed Charges 30501563 LAB/GENERAL CHOLINESTERASE RBC EACH 82482 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $3.96 $3.96 $7.95 65% of Billed Charges 65% of Billed Charges 30501571 LAB/GENERAL CHOLINESTERASE SERUM EACH 82480 $20.00 301 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $4.06 $4.06 $6.37 65% of Billed Charges 65% of Billed Charges 30501589 LAB/GENERAL CHONDROITIN SULFATE QN EACH 82485 $52.00 301 $36.40 $26.00 $41.60 65% of Billed Charges 80% of Billed Charges $10.65 $10.65 $16.73 65% of Billed Charges 65% of Billed Charges 30501597 LAB/GENERAL CHROM ADD BANDING EACH 88283 $192.00 311 $134.40 $96.00 $153.60 65% of Billed Charges 80% of Billed Charges $35.37 $35.37 $55.57 65% of Billed Charges 65% of Billed Charges 30501605 LAB/GENERAL CHROM ADD CELL COUNT EACH 88285 $94.00 311 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges $9.80 $9.80 $21.80 65% of Billed Charges 65% of Billed Charges 30501613 LAB/GENERAL CHROM ADD HIGH RESOLUTION EACH 88289 $146.00 311 $102.20 $73.00 $116.80 65% of Billed Charges 80% of Billed Charges $17.76 $17.76 $27.89 65% of Billed Charges 65% of Billed Charges 30501621 LAB/GENERAL CHROM ADD KARYO EACH 88280 $124.00 311 $86.80 $62.00 $99.20 65% of Billed Charges 80% of Billed Charges $12.94 $12.94 $27.11 65% of Billed Charges 65% of Billed Charges 30501639 LAB/GENERAL CHROM ANLYS ANLYSZE 20 EACH 88264 $362.00 311 $253.40 $181.00 $289.60 65% of Billed Charges 80% of Billed Charges $64.27 $64.27 $117.13 65% of Billed Charges 65% of Billed Charges 30501647 LAB/GENERAL CHROM ANLYS BREAKAGE SYNDROME EACH 88249 $433.00 311 $303.10 $216.50 $346.40 65% of Billed Charges 80% of Billed Charges $89.29 $89.29 $140.27 65% of Billed Charges 65% of Billed Charges 30501654 LAB/GENERAL CHROM ANLYS SISTER CHROMATID EACH 88245 $433.00 311 $303.10 $216.50 $346.40 65% of Billed Charges 80% of Billed Charges $76.76 $76.76 $140.27 65% of Billed Charges 65% of Billed Charges 30501662 LAB/GENERAL CHROM COUNT 15-20/2 EACH 88262 $314.00 311 $219.80 $157.00 $251.20 65% of Billed Charges 80% of Billed Charges $64.27 $64.27 $101.65 65% of Billed Charges 65% of Billed Charges 30501670 LAB/GENERAL CHROM COUNT 45/2 MOSAICISM EACH 88263 $376.00 311 $263.20 $188.00 $300.80 65% of Billed Charges 80% of Billed Charges $77.49 $77.49 $121.73 65% of Billed Charges 65% of Billed Charges 30501688 LAB/GENERAL CHROM COUNT 5/1 EACH 88261 $661.00 311 $462.70 $330.50 $528.80 65% of Billed Charges 80% of Billed Charges $91.13 $91.13 $214.12 65% of Billed Charges 65% of Billed Charges 30501696 LAB/GENERAL CHROM COUNT AMNIOTIC 15/1 EACH 88267 $472.00 311 $330.40 $236.00 $377.60 65% of Billed Charges 80% of Billed Charges $92.69 $92.69 $152.74 65% of Billed Charges 65% of Billed Charges 30501704 LAB/GENERAL CHROM COUNT AMNIOTIC INSITU EACH 88269 $435.00 311 $304.50 $217.50 $348.00 65% of Billed Charges 80% of Billed Charges $85.76 $85.76 $140.66 65% of Billed Charges 65% of Billed Charges 30501712 LAB/GENERAL CHROM COUNT BREAKAGE 100/20/2 EACH 88248 $433.00 311 $303.10 $216.50 $346.40 65% of Billed Charges 80% of Billed Charges $89.29 $89.29 $140.27 65% of Billed Charges 65% of Billed Charges 30501779 LAB/GENERAL CHROMIUM URINE EACH 82495 $51.00 301 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.46 $10.46 $16.43 65% of Billed Charges 65% of Billed Charges 30501811 LAB/GENERAL CLONAZEPAM (KLONOPIN) EACH 80159 $51.00 301 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $9.08 $9.08 $16.32 65% of Billed Charges 65% of Billed Charges 30501829 LAB/GENERAL CLOT LYSIS TIME EACH 85175 $51.00 305 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $2.34 $2.34 $16.50 65% of Billed Charges 65% of Billed Charges 30501837 LAB/GENERAL CLOT RETRACTION EACH 85170 $41.00 305 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $1.86 $1.86 $13.20 65% of Billed Charges 65% of Billed Charges 30501845 LAB/GENERAL CMV ANTIBODY EACH 86644 $36.00 302 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.42 $7.42 $11.66 65% of Billed Charges 65% of Billed Charges 30501860 LAB/GENERAL COAG TIME ACTIVATED (ACT) EACH 85347 $11.00 305 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $2.20 $2.20 $3.47 65% of Billed Charges 65% of Billed Charges 30501878 LAB/GENERAL COAG TIME LEE & WHITE EACH 85345 $12.00 305 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.22 $2.22 $3.80 65% of Billed Charges 65% of Billed Charges 30501886 LAB/GENERAL COAG TIME OTHER EACH 85348 $12.00 305 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $1.92 $1.92 $3.64 65% of Billed Charges 65% of Billed Charges 30501902 LAB/GENERAL COCCIDIOIDES ANTIBODY EACH 86635 $29.00 302 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.91 $5.91 $9.29 65% of Billed Charges 65% of Billed Charges 30501910 LAB/GENERAL COLD AGGLUTININ SCREEN EACH 86156 $21.00 302 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $3.46 $3.46 $6.54 65% of Billed Charges 65% of Billed Charges 30502009 LAB/GENERAL COMPLEMENT FIX RSV EACH 86171 $26.00 302 $18.20 $13.00 $20.80 65% of Billed Charges 80% of Billed Charges $5.17 $5.17 $8.11 65% of Billed Charges 65% of Billed Charges 30512982 LAB/GENERAL COMPLEMENT; ACTIVITY EA CMP EACH 86161 $30.00 302 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.19 $6.19 $9.72 65% of Billed Charges 65% of Billed Charges 30502033 LAB/GENERAL COMPREHENSIVE METABOLIC PANEL EACH 80053 $27.00 301 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $5.45 $5.45 $8.55 65% of Billed Charges 65% of Billed Charges 30502058 LAB/GENERAL CONCENTRATION ANY TYPE EACH 87015 $17.00 300 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 30502074 LAB/GENERAL COPPER SERUM EACH 82525 $32.00 301 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.40 $6.40 $10.05 65% of Billed Charges 65% of Billed Charges 30502090 LAB/GENERAL CORTICOSTERONE EACH 82528 $57.00 301 $39.90 $28.50 $45.60 65% of Billed Charges 80% of Billed Charges $11.61 $11.61 $18.24 65% of Billed Charges 65% of Billed Charges 30512990 LAB/GENERAL CORTISOL FREE URINE EACH 82530 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.62 $8.62 $13.54 65% of Billed Charges 65% of Billed Charges 30502132 LAB/GENERAL CORTISOL TOTAL URINE EACH 82533 $41.00 301 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $8.41 $8.41 $13.20 65% of Billed Charges 65% of Billed Charges 30514483 LAB/GENERAL COVID 19 - IGG ANTIBODY EACH 86769 $106.00 310 $74.20 $53.00 $84.80 65% of Billed Charges 80% of Billed Charges $15.17 $15.17 $42.13 65% of Billed Charges 65% of Billed Charges 30514277 LAB/GENERAL COVID 19 INHOUSE TEST EACH 87635 $129.00 306 $90.30 $64.50 $103.20 65% of Billed Charges 80% of Billed Charges $18.47 $18.47 $51.31 65% of Billed Charges 65% of Billed Charges 30514285 LAB/GENERAL COVID 19 POC TEST EACH 86328 $114.00 306 $79.80 $57.00 $91.20 65% of Billed Charges 80% of Billed Charges $16.30 $16.30 $45.23 65% of Billed Charges 65% of Billed Charges 30502157 LAB/GENERAL COXIELLA BRUNETII (Q FEVER) AB EACH 86638 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.25 $6.25 $9.82 65% of Billed Charges 65% of Billed Charges 30502181 LAB/GENERAL C-REACTIVE PROTEIN EACH 86140 $13.00 302 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.67 $2.67 $4.20 65% of Billed Charges 65% of Billed Charges 30502199 LAB/GENERAL C-REACTIVE PROTEIN HIGH SENS EACH 86141 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.67 $6.67 $10.49 65% of Billed Charges 65% of Billed Charges 30502207 LAB/GENERAL CREATINE BLOOD EACH 82540 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.39 $2.39 $3.76 65% of Billed Charges 65% of Billed Charges 30502215 LAB/GENERAL CREATINE KINASE (CPK) ISOENZ EACH 82552 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.91 $6.91 $10.85 65% of Billed Charges 65% of Billed Charges 30502223 LAB/GENERAL CREATINE KINASE (CPK) MB ONLY EACH 82553 $29.00 301 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.95 $5.95 $9.36 65% of Billed Charges 65% of Billed Charges 30502231 LAB/GENERAL CREATINE KINASE (CPK) TOTAL EACH 82550 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.36 $3.36 $5.27 65% of Billed Charges 65% of Billed Charges 30502256 LAB/GENERAL CREATININE BLOOD EACH 82565 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.64 $2.64 $4.15 65% of Billed Charges 65% of Billed Charges 30502264 LAB/GENERAL CREATININE CLEARANCE EACH 82575 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $4.87 $4.87 $7.66 65% of Billed Charges 65% of Billed Charges 30513006 LAB/GENERAL CREATININE OTHER SOURCE EACH 82570 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.67 $2.67 $4.20 65% of Billed Charges 65% of Billed Charges 30502280 LAB/GENERAL CRYOFIBRINOGEN EACH 82585 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $4.42 $4.42 $11.45 65% of Billed Charges 65% of Billed Charges 30502306 LAB/GENERAL CRYOPRESERVATION EMBRYOS EACH 89258 "$2,127.00 " 309 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $483.81 65% of Billed Charges 65% of Billed Charges 30502314 LAB/GENERAL CRYOPRESERVATION FREEZE & STOR EACH 88240 $33.00 311 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $5.21 $5.21 $10.59 65% of Billed Charges 65% of Billed Charges 30502322 LAB/GENERAL CRYOPRESERVATION SPERM EACH 89259 $423.00 309 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $362.23 65% of Billed Charges 65% of Billed Charges 30502348 LAB/GENERAL CRYSTAL ID LIGHT MICROSCOPY EACH 89060 $35.00 309 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $3.69 $3.69 $5.94 65% of Billed Charges 65% of Billed Charges 30502355 LAB/GENERAL CULT STOOL SALMONELLA/SHIGELLA EACH 87045 $24.00 300 $16.80 $12.00 $19.20 65% 80% 50% 50% 65% 65% 65% 30502363 LAB/GENERAL CULTURE AEROBIC ID EACH 87077 $21.00 300 $14.70 $10.50 $16.80 65% 80% 50% 50% 65% 65% 65% 30502371 LAB/GENERAL CULTURE AEROBIC OTHER QN EACH 87071 $25.00 300 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% 65% 30502389 LAB/GENERAL CULTURE AFB/TB/MYCOBACTERIA EACH 87116 $27.00 300 $18.90 $13.50 $21.60 65% 80% 50% 50% 65% 65% 65% 30502397 LAB/GENERAL CULTURE ANAEROBIC EACH 87075 $24.00 300 $16.80 $12.00 $19.20 65% 80% 50% 50% 65% 65% 65% 30502405 LAB/GENERAL CULTURE ANAEROBIC ID EACH 87076 $21.00 300 $14.70 $10.50 $16.80 65% 80% 50% 50% 65% 65% 65% 30502413 LAB/GENERAL CULTURE ANAEROBIC OTHER QN EACH 87073 $25.00 300 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% 65% 30502421 LAB/GENERAL CULTURE BLOOD EACH 87040 $26.00 300 $18.20 $13.00 $20.80 65% 80% 50% 50% 65% 65% 65% 30502439 LAB/GENERAL CULTURE CHLAMYDIA EACH 87110 $49.00 300 $34.30 $24.50 $39.20 65% 80% 50% 50% 65% 65% 65% 30502447 LAB/GENERAL CULTURE CO-CULT OOCYTE/EMBRYO EACH 89251 $423.00 309 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $865.32 65% of Billed Charges 65% of Billed Charges 30502454 LAB/GENERAL CULTURE FUNGUS BLOOD EACH 87103 $52.00 300 $36.40 $26.00 $41.60 65% 80% 50% 50% 65% 65% 65% 30502462 LAB/GENERAL CULTURE FUNGUS ID MOLD EACH 87107 $26.00 300 $18.20 $13.00 $20.80 65% 80% 50% 50% 65% 65% 65% 30502470 LAB/GENERAL CULTURE FUNGUS ID YEAST EACH 87106 $26.00 300 $18.20 $13.00 $20.80 65% 80% 50% 50% 65% 65% 65% 30502488 LAB/GENERAL CULTURE FUNGUS OTHER EACH 87102 $22.00 300 $15.40 $11.00 $17.60 65% 80% 50% 50% 65% 65% 65% 30502496 LAB/GENERAL CULTURE FUNGUS SKIN/HAIR/NAIL EACH 87101 $20.00 300 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 30502504 LAB/GENERAL CULTURE MYCOBACTERIA ID EACH 87118 $37.00 300 $25.90 $18.50 $29.60 65% 80% 50% 50% 65% 65% 65% 30502512 LAB/GENERAL CULTURE MYCOPLASMA EACH 87109 $39.00 300 $27.30 $19.50 $31.20 65% 80% 50% 50% 65% 65% 65% 30502520 LAB/GENERAL CULTURE OOCYTE/EMBRYOS<4DAY EACH 89250 $423.00 309 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $831.91 65% of Billed Charges 65% of Billed Charges 30502538 LAB/GENERAL CULTURE OTHER SOURCE EACH 87070 $22.00 300 $15.40 $11.00 $17.60 65% 80% 50% 50% 65% 65% 65% 30502546 LAB/GENERAL CULTURE SCREEN BY KIT W/EST EACH 87084 $68.00 300 $47.60 $34.00 $54.40 65% 80% 50% 50% 65% 65% 65% 30502553 LAB/GENERAL CULTURE SCREEN SINGLE ORGANISM EACH 87081 $17.00 300 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 30502561 LAB/GENERAL CULTURE STOOL OTHER EACH 87046 $24.00 300 $16.80 $12.00 $19.20 65% 80% 50% 50% 65% 65% 65% 30502579 LAB/GENERAL CULTURE TYPING CHROMATOGRAPHY EACH 87143 $32.00 300 $22.40 $16.00 $25.60 65% 80% 50% 50% 65% 65% 65% 30502595 LAB/GENERAL CULTURE TYPING ID PULSE FIELD EACH 87152 $20.00 300 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 30502603 LAB/GENERAL CULTURE TYPING IF EA ANTISERUM EACH 87140 $14.00 300 $9.80 $7.00 $11.20 65% 80% 50% 50% 65% 65% 65% 30502611 LAB/GENERAL CULTURE TYPING OTHER METHOD EACH 87158 $20.00 300 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 30502629 LAB/GENERAL CULTURE TYPING SEROLOGIC EACH 87147 $13.00 300 $9.10 $6.50 $10.40 65% 80% 50% 50% 65% 65% 65% 30502645 LAB/GENERAL CULTURE URINE ID EA ISOLATE EACH 87088 $21.00 300 $14.70 $10.50 $16.80 65% 80% 50% 50% 65% 65% 65% 30502652 LAB/GENERAL CULTURE URINE W/COLONY COUNT EACH 87086 $21.00 300 $14.70 $10.50 $16.80 65% 80% 50% 50% 65% 65% 65% 30502660 LAB/GENERAL CULTURE VIRUS ID ADD STUDIES EACH 87253 $51.00 300 $35.70 $25.50 $40.80 65% 80% 50% 50% 65% 65% 65% 30502678 LAB/GENERAL CULTURE VIRUS ID INOC OBSV DIS EACH 87250 $49.00 300 $34.30 $24.50 $39.20 65% 80% 50% 50% 65% 65% 65% 30502694 LAB/GENERAL CYANIDE EACH 82600 $49.00 301 $34.30 $24.50 $39.20 65% of Billed Charges 80% of Billed Charges $10.00 $10.00 $15.71 65% of Billed Charges 65% of Billed Charges 30502710 LAB/GENERAL CYSTINE HOMOCYSTINE QL URINE EACH 82615 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $4.21 $4.21 $7.74 65% of Billed Charges 65% of Billed Charges 30502736 LAB/GENERAL CYTOTOXIC PRA QUICK EACH 86808 $75.00 302 $52.50 $37.50 $60.00 65% of Billed Charges 80% of Billed Charges $15.30 $15.30 $24.04 65% of Billed Charges 65% of Billed Charges 30502744 LAB/GENERAL CYTOTOXIC PRA STANDARD EACH 86807 $197.00 302 $137.90 $98.50 $157.60 65% of Billed Charges 80% of Billed Charges $20.40 $20.40 $63.71 65% of Billed Charges 65% of Billed Charges 30502751 LAB/GENERAL DARK FIELD EXAM W/COLLECTION EACH 87164 $27.00 300 $18.90 $13.50 $21.60 65% 80% 50% 50% 65% 65% 65% 30502769 LAB/GENERAL DARK FIELD EXAM W/O COLLECTION EACH 87166 $29.00 300 $20.30 $14.50 $23.20 65% 80% 50% 50% 65% 65% 65% 30502785 LAB/GENERAL DEOXYRIBONUCLEASE ANTIBODY EACH 86215 $34.00 302 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.83 $6.83 $10.73 65% of Billed Charges 65% of Billed Charges 30502819 LAB/GENERAL DEVIATION STANDARD PROC EACH 86079 $134.00 305 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $44.47 65% of Billed Charges 65% of Billed Charges 30502827 LAB/GENERAL DEXAMETHASONE SUP PANEL EACH 80420 $405.00 301 $283.50 $202.50 $324.00 65% of Billed Charges 80% of Billed Charges $37.14 $37.14 $131.12 65% of Billed Charges 65% of Billed Charges 30502835 LAB/GENERAL DHEA EACH 82626 $64.00 301 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $13.03 $13.03 $20.47 65% of Billed Charges 65% of Billed Charges 30502868 LAB/GENERAL DIBUCAINE NUMBER EACH 82638 $31.00 301 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.31 $6.31 $9.92 65% of Billed Charges 65% of Billed Charges 30502884 LAB/GENERAL DIGOXIN (LANOXIN) EACH 80162 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.85 $6.85 $10.76 65% of Billed Charges 65% of Billed Charges 30502892 LAB/GENERAL DIHYDROCODEINONE EACH 80361 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $12.59 $12.59 $0.01 65% of Billed Charges 65% of Billed Charges 30502934 LAB/GENERAL DIPROPYLACETIC ACID EACH 80164 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.98 $6.98 $10.97 65% of Billed Charges 65% of Billed Charges 30502967 LAB/GENERAL DNA SINGLE STRAND ANTIBODY EACH 86226 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.25 $6.25 $9.81 65% of Billed Charges 65% of Billed Charges 30502975 LAB/GENERAL DOXEPIN EACH 80335 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $8.77 $8.77 $0.01 65% of Billed Charges 65% of Billed Charges 30502983 LAB/GENERAL DRUG ANLYS TISSUE PREP EACH 80307 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $28.73 $28.73 $50.33 65% of Billed Charges 65% of Billed Charges 30503007 LAB/GENERAL DRUG SCREEN MLT CLASS EACH 80306 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $7.18 $7.18 $13.88 65% of Billed Charges 65% of Billed Charges 30503155 LAB/GENERAL EBV EARLY AG ANTIBODY EACH 86663 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.77 $6.77 $10.63 65% of Billed Charges 65% of Billed Charges 30503189 LAB/GENERAL EIA QL ADENOVIRUS ANTIGEN EACH 87301 $30.00 300 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 30503197 LAB/GENERAL EIA QL C DIFFICILE TOX ANTIGEN EACH 87324 $30.00 306 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $9.70 65% of Billed Charges 65% of Billed Charges 30503205 LAB/GENERAL EIA QL C NEOFORM ANTIGEN EACH 87327 $34.00 306 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $10.87 65% of Billed Charges 65% of Billed Charges 30503213 LAB/GENERAL EIA QL CHLAMYDIA TRACH ANTIGEN EACH 87320 $38.00 306 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $12.15 65% of Billed Charges 65% of Billed Charges 30503221 LAB/GENERAL EIA QL CRYPTOSPORIDIUM ANTIGEN EACH 87328 $35.00 306 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $11.19 65% of Billed Charges 65% of Billed Charges 30503239 LAB/GENERAL EIA QL CYTOMEGALOVIRUS ANTIGEN EACH 87332 $30.00 306 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $9.70 65% of Billed Charges 65% of Billed Charges 30503247 LAB/GENERAL EIA QL E COLI 0157 ANTIGEN EACH 87335 $32.00 306 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $10.25 65% of Billed Charges 65% of Billed Charges 30503254 LAB/GENERAL EIA QL E HYSTOLYTICA ANTIGEN EACH 87337 $30.00 306 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $9.70 65% of Billed Charges 65% of Billed Charges 30503262 LAB/GENERAL EIA QL E HYSTOLYTICA DISPAR AG EACH 87336 $40.00 306 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $12.96 65% of Billed Charges 65% of Billed Charges 30503270 LAB/GENERAL EIA QL GIARDIA ANTIGEN EACH 87329 $30.00 306 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $9.70 65% of Billed Charges 65% of Billed Charges 30503288 LAB/GENERAL EIA QL H PYLORI ANTIGEN EACH 87339 $40.00 306 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $12.96 65% of Billed Charges 65% of Billed Charges 30503296 LAB/GENERAL EIA QL H PYLORI ANTIGEN STOOL EACH 87338 $36.00 306 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.42 $7.42 $11.65 65% of Billed Charges 65% of Billed Charges 30503304 LAB/GENERAL EIA QL HEPATITIS B AG NEUT EACH 87341 $26.00 306 $18.20 $13.00 $20.80 65% of Billed Charges 80% of Billed Charges $5.32 $5.32 $8.37 65% of Billed Charges 65% of Billed Charges 30503312 LAB/GENERAL EIA QL HEPATITIS B ANTIGEN EACH 87340 $26.00 306 $18.20 $13.00 $20.80 65% of Billed Charges 80% of Billed Charges $5.32 $5.32 $8.37 65% of Billed Charges 65% of Billed Charges 30503338 LAB/GENERAL EIA QL HEPATITIS DELTA ANTIGEN EACH 87380 $46.00 306 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $8.47 $8.47 $14.87 65% of Billed Charges 65% of Billed Charges 30503361 LAB/GENERAL EIA QL HIV 2 ANTIGEN EACH 87391 $55.00 306 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges $9.10 $9.10 $17.74 65% of Billed Charges 65% of Billed Charges 30503379 LAB/GENERAL EIA QL INFLUENZA A/B ANTIGEN EACH 87400 $36.00 306 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $11.45 65% of Billed Charges 65% of Billed Charges 30503387 LAB/GENERAL EIA QL MLT ANTIGEN EACH 87449 $30.00 306 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $9.70 65% of Billed Charges 65% of Billed Charges 30503403 LAB/GENERAL EIA QL MLT POLY ANTIGEN EACH 87451 $27.00 306 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $4.94 $4.94 $8.51 65% of Billed Charges 65% of Billed Charges 30503411 LAB/GENERAL EIA QL ROTAVIRUS ANTIGEN EACH 87425 $30.00 306 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $9.70 65% of Billed Charges 65% of Billed Charges 30503429 LAB/GENERAL EIA QL RSV ANTIGEN EACH 87420 $35.00 306 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $11.27 65% of Billed Charges 65% of Billed Charges 30503445 LAB/GENERAL EIA QL SHIGELLA-LIKE TXN AG EACH 87427 $30.00 306 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $9.70 65% of Billed Charges 65% of Billed Charges 30503452 LAB/GENERAL EIA QL STREP GROUP A AG EACH 87430 $43.00 306 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $13.62 65% of Billed Charges 65% of Billed Charges 30503460 LAB/GENERAL ELECTROLYTE PANEL EACH 80051 $18.00 301 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.62 $3.62 $5.68 65% of Billed Charges 65% of Billed Charges 30503478 LAB/GENERAL ELECTROPHORETIC TEST EACH 82664 $154.00 301 $107.80 $77.00 $123.20 65% of Billed Charges 80% of Billed Charges $17.72 $17.72 $49.82 65% of Billed Charges 65% of Billed Charges 30503486 LAB/GENERAL EMBRYO HATCHING MICROTECHNIQUE EACH 89253 $423.00 309 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $225.00 65% of Billed Charges 65% of Billed Charges 30503494 LAB/GENERAL EMBRYO PREP EACH 89255 $134.00 309 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $296.88 65% of Billed Charges 65% of Billed Charges 30513014 LAB/GENERAL ENA AB EACH 86235 $45.00 302 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.25 $9.25 $14.52 65% of Billed Charges 65% of Billed Charges 30503551 LAB/GENERAL ENCEPHALITIS CALIFORNIA AB EACH 86651 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30503577 LAB/GENERAL ENCEPHALITIS ST LOUIS ANTIBODY EACH 86653 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30503593 LAB/GENERAL ENCEPHALITIS WEST EQ ANTIBODY EACH 86654 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30511141 LAB/GENERAL EPSTEIN-BARR ANTIBODY EACH 86664 $39.00 300 $27.30 $19.50 $31.20 65% 80% 50% 50% 65% 65% 65% 30503627 LAB/GENERAL ESTRADIOL EACH 82670 $70.00 301 $49.00 $35.00 $56.00 65% of Billed Charges 80% of Billed Charges $14.41 $14.41 $22.63 65% of Billed Charges 65% of Billed Charges 30503643 LAB/GENERAL ESTROGEN FRACTIONATED EACH 82671 $81.00 301 $56.70 $40.50 $64.80 65% of Billed Charges 80% of Billed Charges $16.65 $16.65 $26.16 65% of Billed Charges 65% of Billed Charges 30503650 LAB/GENERAL ESTROGEN TOTAL EACH 82672 $55.00 301 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges $11.19 $11.19 $17.58 65% of Billed Charges 65% of Billed Charges 30503668 LAB/GENERAL ESTRONE EACH 82679 $63.00 301 $44.10 $31.50 $50.40 65% of Billed Charges 80% of Billed Charges $12.87 $12.87 $20.21 65% of Billed Charges 65% of Billed Charges 30503700 LAB/GENERAL ETIOCHOLANOLONE EACH 82696 $66.00 301 $46.20 $33.00 $52.80 65% of Billed Charges 80% of Billed Charges $12.16 $12.16 $21.25 65% of Billed Charges 65% of Billed Charges 30503718 LAB/GENERAL EUGLOBULIN LYSIS EACH 85360 $22.00 305 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges $4.33 $4.33 $6.81 65% of Billed Charges 65% of Billed Charges 30503726 LAB/GENERAL EXT CULTURE OOCYTES 4-7DAYS EACH 89272 "$2,127.00 " 309 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $501.35 65% of Billed Charges 65% of Billed Charges 30503734 LAB/GENERAL FACTOR II EACH 85210 $33.00 305 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.70 $6.70 $10.51 65% of Billed Charges 65% of Billed Charges 30503791 LAB/GENERAL FACTOR VIII RELATED ANTIGEN EACH 85244 $52.00 305 $36.40 $26.00 $41.60 65% of Billed Charges 80% of Billed Charges $10.53 $10.53 $16.54 65% of Billed Charges 65% of Billed Charges 30503809 LAB/GENERAL FACTOR VIII VW ANTIGEN EACH 85246 $58.00 305 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges $11.83 $11.83 $18.58 65% of Billed Charges 65% of Billed Charges 30513022 LAB/GENERAL FACTOR VIII VW RISTOCETN CF EACH 85245 $58.00 305 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges $11.83 $11.83 $18.58 65% of Billed Charges 65% of Billed Charges 30503866 LAB/GENERAL FACTOR XIII FIBRIN STABLIZING EACH 85290 $41.00 305 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $8.43 $8.43 $13.24 65% of Billed Charges 65% of Billed Charges 30503908 LAB/GENERAL FAT LIPIDS FECES QN EACH 82710 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.66 $8.66 $13.61 65% of Billed Charges 65% of Billed Charges 30503916 LAB/GENERAL FATTY ACIDS NONESTERIFIED EACH 82725 $47.00 301 $32.90 $23.50 $37.60 65% of Billed Charges 80% of Billed Charges $6.87 $6.87 $15.20 65% of Billed Charges 65% of Billed Charges 30503924 LAB/GENERAL FATTY ACIDS VERY LONG CHAIN EACH 82726 $50.00 301 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $9.31 $9.31 $16.00 65% of Billed Charges 65% of Billed Charges 30503940 LAB/GENERAL FDP FSP PARACOAG EACH 85366 $202.00 305 $141.40 $101.00 $161.60 65% of Billed Charges 80% of Billed Charges $4.44 $4.44 $65.17 65% of Billed Charges 65% of Billed Charges 30503957 LAB/GENERAL FDP/FSP AGGLUTINATION SQ EACH 85362 $18.00 305 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.55 $3.55 $5.58 65% of Billed Charges 65% of Billed Charges 30503973 LAB/GENERAL FERRITIN EACH 82728 $35.00 301 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.02 $7.02 $11.04 65% of Billed Charges 65% of Billed Charges 30503981 LAB/GENERAL FETAL HGB KLEIHAUER BETKE EACH 85460 $20.00 305 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $3.99 $3.99 $6.26 65% of Billed Charges 65% of Billed Charges 30503999 LAB/GENERAL FIBRIN DEG D-DIMER QL/SQ EACH 85378 $25.00 305 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $3.68 $3.68 $7.87 65% of Billed Charges 65% of Billed Charges 30504005 LAB/GENERAL FIBRINOGEN ACTIVITY EACH 85384 $25.00 305 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $4.38 $4.38 $7.87 65% of Billed Charges 65% of Billed Charges 30504013 LAB/GENERAL FIBRINOGEN ANTIGEN EACH 85385 $37.00 305 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $4.38 $4.38 $11.71 65% of Billed Charges 65% of Billed Charges 30504021 LAB/GENERAL FIBRINOLYSINS SCR INTERP RPT EACH 85390 $39.00 305 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $2.66 $2.66 $12.54 65% of Billed Charges 65% of Billed Charges 30504039 LAB/GENERAL FIBRINOLYTIC FACTOR PLASMIN EACH 85400 $20.00 305 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $4.56 $4.56 $6.25 65% of Billed Charges 65% of Billed Charges 30513048 LAB/GENERAL FLUOR AB TTR EACH 86256 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.21 $6.21 $9.76 65% of Billed Charges 65% of Billed Charges 30504104 LAB/GENERAL FLUORIDE EACH 82735 $47.00 301 $32.90 $23.50 $37.60 65% of Billed Charges 80% of Billed Charges $9.56 $9.56 $15.02 65% of Billed Charges 65% of Billed Charges 30504138 LAB/GENERAL FOLIC ACID RBC EACH 82747 $45.00 301 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $8.93 $8.93 $14.30 65% of Billed Charges 65% of Billed Charges 30504146 LAB/GENERAL FOLIC ACID SERUM EACH 82746 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.58 $7.58 $11.91 65% of Billed Charges 65% of Billed Charges 30504153 LAB/GENERAL FOLLICLE STIM HORMONE (FSH) EACH 83001 $47.00 301 $32.90 $23.50 $37.60 65% of Billed Charges 80% of Billed Charges $9.58 $9.58 $15.05 65% of Billed Charges 65% of Billed Charges 30504161 LAB/GENERAL FRUCTOSE SEMEN EACH 82757 $44.00 301 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $8.94 $8.94 $14.05 65% of Billed Charges 65% of Billed Charges 30504179 LAB/GENERAL FTA ANTIBODY CONFIRM EACH 86780 $34.00 302 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.83 $6.83 $10.72 65% of Billed Charges 65% of Billed Charges 30504195 LAB/GENERAL G6PD ENZYME SCREEN EACH 82960 $16.00 301 $11.20 $8.00 $12.80 65% of Billed Charges 80% of Billed Charges $3.12 $3.12 $4.90 65% of Billed Charges 65% of Billed Charges 30504211 LAB/GENERAL GALACTOKINASE RBC EACH 82759 $54.00 301 $37.80 $27.00 $43.20 65% of Billed Charges 80% of Billed Charges $11.08 $11.08 $17.40 65% of Billed Charges 65% of Billed Charges 30504229 LAB/GENERAL GALACTOSE EACH 82760 $28.00 301 $19.60 $14.00 $22.40 65% of Billed Charges 80% of Billed Charges $5.77 $5.77 $9.07 65% of Billed Charges 65% of Billed Charges 30504237 LAB/GENERAL GALACTOSE TRANSFERASE QN EACH 82775 $53.00 301 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $10.86 $10.86 $17.07 65% of Billed Charges 65% of Billed Charges 30504245 LAB/GENERAL GALACTOSE TRANSFERASE SCREEN EACH 82776 $30.00 301 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $4.32 $4.32 $9.51 65% of Billed Charges 65% of Billed Charges 30513063 LAB/GENERAL GAMMAGLOBULIN IGA EACH 82784 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $4.80 $4.80 $7.53 65% of Billed Charges 65% of Billed Charges 30511059 LAB/GENERAL "GASTRIC ACID ANALYSIS, INC PH " EACH 82930 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $2.76 $2.76 $5.44 65% of Billed Charges 65% of Billed Charges 30504401 LAB/GENERAL GASTRIN AFTER STIMULATION EACH 82938 $45.00 301 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.13 $9.13 $14.33 65% of Billed Charges 65% of Billed Charges 30504427 LAB/GENERAL GENTAMICIN EACH 80170 $41.00 301 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $8.45 $8.45 $13.27 65% of Billed Charges 65% of Billed Charges 30504435 LAB/GENERAL GGT/GGTP EACH 82977 $18.00 301 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.71 $3.71 $5.83 65% of Billed Charges 65% of Billed Charges 30504443 LAB/GENERAL GIARDIA LAMBLIA ANTIBODY EACH 86674 $37.00 302 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.59 $7.59 $11.92 65% of Billed Charges 65% of Billed Charges 30504468 LAB/GENERAL GLUCAGON TOLERANCE EACH 82946 $45.00 301 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $7.77 $7.77 $14.39 65% of Billed Charges 65% of Billed Charges 30504476 LAB/GENERAL GLUCOSE BLOOD EACH 82947 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $2.02 $2.02 $3.18 65% of Billed Charges 65% of Billed Charges 30504492 LAB/GENERAL GLUCOSE POST DOSE EACH 82950 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.45 $2.45 $3.85 65% of Billed Charges 65% of Billed Charges 30504500 LAB/GENERAL GLUCOSE REAGENT STRIP EACH 82948 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $1.63 $1.63 $4.08 65% of Billed Charges 65% of Billed Charges 30504518 LAB/GENERAL GLUCOSE TOLBUTAMIDE TOLERANCE EACH 82951 $33.00 301 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.64 $6.64 $10.42 65% of Billed Charges 65% of Billed Charges 30504534 LAB/GENERAL GLUCOSE TOLERANCE ADD SPEC EACH 82952 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $2.02 $2.02 $3.18 65% of Billed Charges 65% of Billed Charges 30504559 LAB/GENERAL GLUCOSIDASE BETA EACH 82963 $54.00 301 $37.80 $27.00 $43.20 65% of Billed Charges 80% of Billed Charges $11.08 $11.08 $17.40 65% of Billed Charges 65% of Billed Charges 30504567 LAB/GENERAL GLUTAMATE DEHYDROGENASE EACH 82965 $33.00 301 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $3.99 $3.99 $10.65 65% of Billed Charges 65% of Billed Charges 30504575 LAB/GENERAL GLUTAMINE EACH 82127 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.15 $7.15 $11.49 65% of Billed Charges 65% of Billed Charges 30504583 LAB/GENERAL GLUTATHIONE EACH 82978 $39.00 301 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $7.35 $7.35 $12.51 65% of Billed Charges 65% of Billed Charges 30504591 LAB/GENERAL GLUTATHIONE REDUCTASE RBC EACH 82979 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $3.55 $3.55 $7.65 65% of Billed Charges 65% of Billed Charges 30504633 LAB/GENERAL GROWTH HORMONE (HGH) EACH 83003 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.60 $8.60 $13.50 65% of Billed Charges 65% of Billed Charges 30504641 LAB/GENERAL GROWTH HORMONE STIMULAT PANEL EACH 80428 $167.00 301 $116.90 $83.50 $133.60 65% of Billed Charges 80% of Billed Charges $34.39 $34.39 $54.03 65% of Billed Charges 65% of Billed Charges 30504658 LAB/GENERAL GROWTH HORMONE SUPPRESS PANEL EACH 80430 $324.00 301 $226.80 $162.00 $259.20 65% of Billed Charges 80% of Billed Charges $40.46 $40.46 $104.76 65% of Billed Charges 65% of Billed Charges 30504666 LAB/GENERAL GUANOSINE MONOPHOSPHATE (GMP) EACH 83006 $189.00 301 $132.30 $94.50 $151.20 65% of Billed Charges 80% of Billed Charges $10.77 $10.77 $61.24 65% of Billed Charges 65% of Billed Charges 30504674 LAB/GENERAL H PYLORI ANTIBODY EACH 86677 $43.00 302 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $7.48 $7.48 $13.65 65% of Billed Charges 65% of Billed Charges 30504682 LAB/GENERAL H PYLORI BREATH TEST ANLY C-13 EACH 83013 $169.00 301 $118.30 $84.50 $135.20 65% of Billed Charges 80% of Billed Charges $34.73 $34.73 $54.56 65% of Billed Charges 65% of Billed Charges 30504690 LAB/GENERAL H PYLORI UREASE ANLYS BLOOD EACH 83009 $169.00 301 $118.30 $84.50 $135.20 65% of Billed Charges 80% of Billed Charges $34.73 $34.73 $54.56 65% of Billed Charges 65% of Billed Charges 30504708 LAB/GENERAL HAEMOPHILUS INFLUENZA ANTIBODY EACH 86684 $40.00 302 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $8.17 $8.17 $12.83 65% of Billed Charges 65% of Billed Charges 30504724 LAB/GENERAL HAPTOGLOBIN PHENOTYPES EACH 83012 $68.00 301 $47.60 $34.00 $54.40 65% of Billed Charges 80% of Billed Charges $8.87 $8.87 $21.78 65% of Billed Charges 65% of Billed Charges 30504740 LAB/GENERAL HCG QL EACH 84703 $19.00 301 $13.30 $9.50 $15.20 65% of Billed Charges 80% of Billed Charges $3.87 $3.87 $6.09 65% of Billed Charges 65% of Billed Charges 30513089 LAB/GENERAL HCG QN EACH 84702 $38.00 301 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.76 $7.76 $12.19 65% of Billed Charges 65% of Billed Charges 30504773 LAB/GENERAL HEAVY METAL QN EA EACH 83018 $55.00 301 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges $11.33 $11.33 $17.79 65% of Billed Charges 65% of Billed Charges 30504799 LAB/GENERAL HEAVY METAL SCREEN URINE EACH 83015 $53.00 301 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $9.71 $9.71 $16.96 65% of Billed Charges 65% of Billed Charges 30504807 LAB/GENERAL HEINZ BODIES DIRECT EACH 85441 $11.00 305 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $2.17 $2.17 $3.40 65% of Billed Charges 65% of Billed Charges 30504815 LAB/GENERAL HEINZ BODIES INDUCED EACH 85445 $18.00 305 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.51 $3.51 $5.52 65% of Billed Charges 65% of Billed Charges 30511158 LAB/GENERAL HELMINTH ANTIBODY EACH 86682 $33.00 300 $23.10 $16.50 $26.40 65% 80% 50% 50% 65% 65% 65% 30504823 LAB/GENERAL HEMAGGLUTIN INHIBITION EACH 86280 $21.00 302 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $4.22 $4.22 $6.63 65% of Billed Charges 65% of Billed Charges 30504831 LAB/GENERAL HEMATOCRIT EACH 85014 $6.00 305 $4.20 $3.00 $4.80 65% of Billed Charges 80% of Billed Charges $1.22 $1.22 $1.92 65% of Billed Charges 65% of Billed Charges 30504849 LAB/GENERAL HEMATOLOGY UNLSTD PROC EACH 85999 $162.00 305 $113.40 $81.00 $129.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 30504856 LAB/GENERAL HEMOGLOBIN EACH 85018 $6.00 305 $4.20 $3.00 $4.80 65% of Billed Charges 80% of Billed Charges $1.22 $1.22 $1.92 65% of Billed Charges 65% of Billed Charges 30504864 LAB/GENERAL HEMOGLOBIN ELECTROPHORESIS EACH 83020 $33.00 301 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.64 $6.64 $10.42 65% of Billed Charges 65% of Billed Charges 30504872 LAB/GENERAL HEMOGLOBIN FETAL EACH 83030 $27.00 301 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $4.27 $4.27 $8.70 65% of Billed Charges 65% of Billed Charges 30504880 LAB/GENERAL HEMOGLOBIN FETAL QL EACH 83033 $20.00 301 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $3.07 $3.07 $6.48 65% of Billed Charges 65% of Billed Charges 30504898 LAB/GENERAL HEMOGLOBIN FRACT QN EACH 83021 $46.00 301 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $9.31 $9.31 $14.63 65% of Billed Charges 65% of Billed Charges 30504906 LAB/GENERAL HEMOGLOBIN FREE EACH 83051 $19.00 301 $13.30 $9.50 $15.20 65% of Billed Charges 80% of Billed Charges $3.77 $3.77 $5.92 65% of Billed Charges 65% of Billed Charges 30504914 LAB/GENERAL HEMOGLOBIN GLYCOSYLATED (A1C) EACH 83036 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $5.00 $5.00 $7.87 65% of Billed Charges 65% of Billed Charges 30504930 LAB/GENERAL HEMOGLOBIN STABILITY SCREEN EACH 83068 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $4.37 $4.37 $7.67 65% of Billed Charges 65% of Billed Charges 30504948 LAB/GENERAL HEMOGLOBIN THERMOLABILE EACH 83065 $23.00 301 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $3.55 $3.55 $7.29 65% of Billed Charges 65% of Billed Charges 30504955 LAB/GENERAL HEMOGLOBIN URINE EACH 83069 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $2.03 $2.03 $3.20 65% of Billed Charges 65% of Billed Charges 30504963 LAB/GENERAL HEMOLYSIN ACID EACH 85475 $23.00 305 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $4.58 $4.58 $7.18 65% of Billed Charges 65% of Billed Charges 30504997 LAB/GENERAL HEMOSIDERIN QN EACH 83070 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.45 $2.45 $3.85 65% of Billed Charges 65% of Billed Charges 30505002 LAB/GENERAL HEPARIN ASSAY EACH 85520 $33.00 305 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.75 $6.75 $10.60 65% of Billed Charges 65% of Billed Charges 30505010 LAB/GENERAL HEPARIN NEUTRALIZATION EACH 85525 $30.00 305 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.11 $6.11 $9.59 65% of Billed Charges 65% of Billed Charges 30505028 LAB/GENERAL HEPARIN PROTAMINE TOLERANCE EACH 85530 $33.00 305 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $7.31 $7.31 $10.60 65% of Billed Charges 65% of Billed Charges 30505036 LAB/GENERAL HEPATIC FUNCTION PANEL EACH 80076 $21.00 301 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $4.21 $4.21 $6.62 65% of Billed Charges 65% of Billed Charges 30505044 LAB/GENERAL HEPATITIS A AB (HAAB) IGM EACH 86709 $29.00 302 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.80 $5.80 $9.12 65% of Billed Charges 65% of Billed Charges 30505051 LAB/GENERAL HEPATITIS A AB (HAAB) TOTAL EACH 86708 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.39 $6.39 $10.04 65% of Billed Charges 65% of Billed Charges 30505069 LAB/GENERAL HEPATITIS B CORE AB IGM EACH 86705 $30.00 302 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.07 $6.07 $9.53 65% of Billed Charges 65% of Billed Charges 30505077 LAB/GENERAL HEPATITIS B CORE ANTIBODY EACH 86704 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.21 $6.21 $9.76 65% of Billed Charges 65% of Billed Charges 30505085 LAB/GENERAL HEPATITIS B SURFACE ANTIBODY EACH 86706 $27.00 302 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $5.54 $5.54 $8.70 65% of Billed Charges 65% of Billed Charges 30505119 LAB/GENERAL HEPATITIS C ANTIBODY EACH 86803 $36.00 302 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.36 $7.36 $11.56 65% of Billed Charges 65% of Billed Charges 30505135 LAB/GENERAL HERPES SMPX I ANTIBODY EACH 86695 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30505150 LAB/GENERAL HERPES SMPX II ANTIBODY IGG EACH 86696 $49.00 302 $34.30 $24.50 $39.20 65% of Billed Charges 80% of Billed Charges $9.98 $9.98 $15.67 65% of Billed Charges 65% of Billed Charges 30505176 LAB/GENERAL HETEROPHILE ANTIBODY TITER EACH 86309 $17.00 302 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.24 65% of Billed Charges 65% of Billed Charges 30505184 LAB/GENERAL HETEROPHILE ANTIBODY TTR ABSOR EACH 86310 $19.00 302 $13.30 $9.50 $15.20 65% of Billed Charges 80% of Billed Charges $3.80 $3.80 $5.97 65% of Billed Charges 65% of Billed Charges 30512313 LAB/GENERAL "HFE GENE, COMMON VARIANTS " EACH 81256 $164.00 310 $114.80 $82.00 $131.20 65% of Billed Charges 80% of Billed Charges $32.10 $32.10 $52.94 65% of Billed Charges 65% of Billed Charges 30505192 LAB/GENERAL HGB GLYCOSYLATED HB A1C HOME EACH 83037 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $5.00 $5.00 $7.87 65% of Billed Charges 65% of Billed Charges 30505200 LAB/GENERAL HISTAMINE BLOOD EACH 83088 $74.00 301 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $15.23 $15.23 $23.92 65% of Billed Charges 65% of Billed Charges 30505226 LAB/GENERAL HISTOPLASMA ANTIBODY EACH 86698 $35.00 302 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $6.45 $6.45 $11.17 65% of Billed Charges 65% of Billed Charges 30505234 LAB/GENERAL HIV 1 ANTIBODY EACH 86701 $23.00 302 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $4.58 $4.58 $7.20 65% of Billed Charges 65% of Billed Charges 30515589 LAB/GENERAL "HIV 1,2 AB AND AG COMBO (POC) " EACH 87806 $82.00 300 $57.40 $41.00 $65.60 65% 80% 50% 50% 65% 65% 65% 30505259 LAB/GENERAL HIV 2 ANTIBODY EACH 86702 $34.00 302 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.97 $6.97 $10.95 65% of Billed Charges 65% of Billed Charges 30512636 LAB/GENERAL HIV-1 AG W/HIV-1 & HIV-2 AB EACH 87389 $61.00 306 $42.70 $30.50 $48.80 65% of Billed Charges 80% of Billed Charges $12.28 $12.28 $19.50 65% of Billed Charges 65% of Billed Charges 30505242 LAB/GENERAL HIV1 HIV2 ANTIBODY SGL RES EACH 86703 $35.00 302 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.07 $7.07 $11.11 65% of Billed Charges 65% of Billed Charges 30505267 LAB/GENERAL HLA TYPING MLT ANTIGEN A/B/C EACH 86813 $145.00 302 $101.50 $72.50 $116.00 65% of Billed Charges 80% of Billed Charges $29.90 $29.90 $46.98 65% of Billed Charges 65% of Billed Charges 30505275 LAB/GENERAL HLA TYPING MLT ANTIGEN DR DQ EACH 86817 $266.00 302 $186.20 $133.00 $212.80 65% of Billed Charges 80% of Billed Charges $33.20 $33.20 $85.97 65% of Billed Charges 65% of Billed Charges 30505283 LAB/GENERAL HLA TYPING SINGLE AG A/B/C EACH 86812 $65.00 302 $45.50 $32.50 $52.00 65% of Billed Charges 80% of Billed Charges $13.31 $13.31 $20.91 65% of Billed Charges 65% of Billed Charges 30505291 LAB/GENERAL HLA TYPING SINGLE AG DR DQ EACH 86816 $76.00 302 $53.20 $38.00 $60.80 65% of Billed Charges 80% of Billed Charges $14.36 $14.36 $24.44 65% of Billed Charges 65% of Billed Charges 30505317 LAB/GENERAL HOMOGENIZATION TISSUE EACH 87176 $15.00 300 $10.50 $7.50 $12.00 65% 80% 50% 50% 65% 65% 65% 30505325 LAB/GENERAL HOMOVANILLIC ACID (HVA) URINE EACH 83150 $57.00 301 $39.90 $28.50 $45.60 65% of Billed Charges 80% of Billed Charges $9.98 $9.98 $18.15 65% of Billed Charges 65% of Billed Charges 30513303 LAB/GENERAL HPV GENOTYPE EACH 87625 $102.00 306 $71.40 $51.00 $81.60 65% of Billed Charges 80% of Billed Charges $17.19 $17.19 $32.85 65% of Billed Charges 65% of Billed Charges 30505333 LAB/GENERAL HTLV I ANTIBODY EACH 86687 $23.00 302 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $4.33 $4.33 $7.36 65% of Billed Charges 65% of Billed Charges 30505341 LAB/GENERAL HTLV II ANTIBODY EACH 86688 $35.00 302 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.23 $7.23 $11.34 65% of Billed Charges 65% of Billed Charges 30505366 LAB/GENERAL HUMAN GROWTH HORMONE ANTIBODY EACH 86277 $40.00 302 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $8.11 $8.11 $12.75 65% of Billed Charges 65% of Billed Charges 30505374 LAB/GENERAL HYDROXYCORTICOSTEROID 17 BLOOD EACH 83491 $45.00 301 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.03 $9.03 $14.50 65% of Billed Charges 65% of Billed Charges 30505390 LAB/GENERAL HYDROXYINDOLACETIC 5-(HIAA) BL EACH 83497 $33.00 301 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.65 $6.65 $10.45 65% of Billed Charges 65% of Billed Charges 30505432 LAB/GENERAL HYDROXYPROLINE FREE BLOOD EACH 83500 $57.00 301 $39.90 $28.50 $45.60 65% of Billed Charges 80% of Billed Charges $11.68 $11.68 $18.35 65% of Billed Charges 65% of Billed Charges 30505457 LAB/GENERAL HYDROXYPROLINE TOTAL EACH 83505 $61.00 301 $42.70 $30.50 $48.80 65% of Billed Charges 80% of Billed Charges $12.54 $12.54 $19.68 65% of Billed Charges 65% of Billed Charges 30502587 LAB/GENERAL ID NUCLEIC ACID - AMPLIFIED EACH 87149 $51.00 300 $35.70 $25.50 $40.80 65% 80% 50% 50% 65% 65% 65% 30512164 LAB/GENERAL ID NUCLEIC ACID - DIRECT EACH 87150 $88.00 300 $61.60 $44.00 $70.40 65% 80% 50% 50% 65% 65% 65% 30505465 LAB/GENERAL IF ADENOVIRUS ANTIGEN EACH 87260 $37.00 300 $25.90 $18.50 $29.60 65% 80% 50% 50% 65% 65% 65% 30505473 LAB/GENERAL IF AG NOT SPECIFIED EACH 87299 $41.00 300 $28.70 $20.50 $32.80 65% 80% 50% 50% 65% 65% 65% 30505481 LAB/GENERAL IF BORDETELLA P ANTIGEN EACH 87265 $30.00 300 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 30505499 LAB/GENERAL IF CHLAMYDIA T ANTIGEN EACH 87270 $30.00 300 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 30505507 LAB/GENERAL IF CRYPTOSPORIDIUM ANTIGEN EACH 87272 $30.00 300 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 30505515 LAB/GENERAL IF CYTOMEGALOVIRUS ANTIGEN EACH 87271 $34.00 300 $23.80 $17.00 $27.20 65% 80% 50% 50% 65% 65% 65% 30505523 LAB/GENERAL IF ENTEROVIRUS ANTIGEN EACH 87267 $34.00 300 $23.80 $17.00 $27.20 65% 80% 50% 50% 65% 65% 65% 30505531 LAB/GENERAL IF HERPES SMPX 2 ANTIGEN EACH 87273 $30.00 300 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 30505549 LAB/GENERAL IF HERPES SMPX ANTIGEN EACH 87274 $30.00 300 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 30505556 LAB/GENERAL IF INDIRECT CENTROMERE EACH 88350 $407.00 312 $284.90 $203.50 $325.60 65% of Billed Charges 80% of Billed Charges $15.74 $15.74 $79.26 65% of Billed Charges 65% of Billed Charges 30505564 LAB/GENERAL IF INFLUENZA A ANTIGEN EACH 87276 $41.00 300 $28.70 $20.50 $32.80 65% 80% 50% 50% 65% 65% 65% 30505572 LAB/GENERAL IF INFLUENZA B ANTIGEN EACH 87275 $31.00 300 $21.70 $15.50 $24.80 65% 80% 50% 50% 65% 65% 65% 30505580 LAB/GENERAL IF LEGIONELLA ANTIGEN EACH 87278 $39.00 300 $27.30 $19.50 $31.20 65% 80% 50% 50% 65% 65% 65% 30505606 LAB/GENERAL IF PARAINFLUENZA ANTIGEN EACH 87279 $42.00 300 $29.40 $21.00 $33.60 65% 80% 50% 50% 65% 65% 65% 30505614 LAB/GENERAL IF PNEUMOCYST CARINII ANTIGEN EACH 87281 $30.00 300 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 30505622 LAB/GENERAL IF POLYVALENT MLT ORG ANTIGEN EACH 87300 $30.00 300 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 30505630 LAB/GENERAL IF RSV ANTIGEN EACH 87280 $34.00 300 $23.80 $17.00 $27.20 65% 80% 50% 50% 65% 65% 65% 30505648 LAB/GENERAL IF RUBEOLA ANTIGEN EACH 87283 $152.00 300 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% 65% 65% 30505655 LAB/GENERAL IF TREPONEMA P ANTIGEN EACH 87285 $31.00 300 $21.70 $15.50 $24.80 65% 80% 50% 50% 65% 65% 65% 30505663 LAB/GENERAL IF VARICELLA-ZOSTER ANTIGEN EACH 87290 $34.00 300 $23.80 $17.00 $27.20 65% 80% 50% 50% 65% 65% 65% 30514996 LAB/GENERAL IGH VARI REGIONAL MUTATION EACH 81263 $737.00 310 $515.90 $368.50 $589.60 65% of Billed Charges 80% of Billed Charges $144.64 $144.64 $238.56 65% of Billed Charges 65% of Billed Charges 30512305 LAB/GENERAL "IKBKAP GENE, COMMOM VARIANTS " EACH 81260 $99.00 310 $69.30 $49.50 $79.20 65% of Billed Charges 80% of Billed Charges $14.15 $14.15 $31.84 65% of Billed Charges 65% of Billed Charges 30505697 LAB/GENERAL IMMUNE CPLX ASY RAJI CELL EACH 86332 $61.00 302 $42.70 $30.50 $48.80 65% of Billed Charges 80% of Billed Charges $12.57 $12.57 $19.74 65% of Billed Charges 65% of Billed Charges 30505705 LAB/GENERAL IMMUNO INFECTIOUS AB QL SQ EACH 86318 $46.00 302 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $6.67 $6.67 $14.65 65% of Billed Charges 65% of Billed Charges 30505713 LAB/GENERAL IMMUNO INFECTIOUS AB QN EACH 86317 $38.00 302 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.73 $7.73 $12.14 65% of Billed Charges 65% of Billed Charges 30505721 LAB/GENERAL IMMUNO OPTIC ADENOVIRUS EACH 87809 $55.00 306 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $17.63 65% of Billed Charges 65% of Billed Charges 30505739 LAB/GENERAL IMMUNO OPTICAL C DIFF A TOXIN EACH 87803 $40.00 306 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $12.96 65% of Billed Charges 65% of Billed Charges 30505747 LAB/GENERAL IMMUNO OPTICAL CHLAMYDIA EACH 87810 $89.00 306 $62.30 $44.50 $71.20 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $28.58 65% of Billed Charges 65% of Billed Charges 30505754 LAB/GENERAL IMMUNO OPTICAL GC EACH 87850 $62.00 306 $43.40 $31.00 $49.60 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $19.89 65% of Billed Charges 65% of Billed Charges 30505762 LAB/GENERAL IMMUNO OPTICAL INFLUENZA EACH 87804 $42.00 306 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $13.41 65% of Billed Charges 65% of Billed Charges 30505770 LAB/GENERAL IMMUNO OPTICAL RSV EACH 87807 $33.00 306 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $10.61 65% of Billed Charges 65% of Billed Charges 30505788 LAB/GENERAL IMMUNO OPTICAL STREP A EACH 87880 $42.00 306 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $13.39 65% of Billed Charges 65% of Billed Charges 30505796 LAB/GENERAL IMMUNO OPTICAL STREP B EACH 87802 $32.00 306 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $10.31 65% of Billed Charges 65% of Billed Charges 30505820 LAB/GENERAL IMMUNO TUMR AG CA 125 EACH 86304 $53.00 302 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $10.73 $10.73 $16.86 65% of Billed Charges 65% of Billed Charges 30505846 LAB/GENERAL IMMUNO TUMR AG CA 19-9 EACH 86301 $53.00 302 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $10.73 $10.73 $16.86 65% of Billed Charges 65% of Billed Charges 30505853 LAB/GENERAL IMMUNO TUMR AG OTHER AG QN EACH 86316 $53.00 302 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $10.73 $10.73 $16.86 65% of Billed Charges 65% of Billed Charges 30505861 LAB/GENERAL IMMUNO TUMR AG QL SQ EACH 86294 $64.00 302 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $10.12 $10.12 $20.71 65% of Billed Charges 65% of Billed Charges 30513097 LAB/GENERAL IMMUNODIFF GEL EA AG AB QL EACH 86331 $30.00 302 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $9.70 65% of Billed Charges 65% of Billed Charges 30505895 LAB/GENERAL IMMUNODIFFUSION EACH 86329 $36.00 302 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.24 $7.24 $11.38 65% of Billed Charges 65% of Billed Charges 30505903 LAB/GENERAL IMMUNOELECTROPHORESIS CROSSED EACH 86327 $75.00 302 $52.50 $37.50 $60.00 65% of Billed Charges 80% of Billed Charges $11.70 $11.70 $24.24 65% of Billed Charges 65% of Billed Charges 30505929 LAB/GENERAL IMMUNOELECTROPHORESIS OTHER EACH 86325 $58.00 302 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges $11.53 $11.53 $18.74 65% of Billed Charges 65% of Billed Charges 30505937 LAB/GENERAL IMMUNOELECTROPHORESIS SERUM EACH 86320 $75.00 302 $52.50 $37.50 $60.00 65% of Billed Charges 80% of Billed Charges $11.56 $11.56 $24.24 65% of Billed Charges 65% of Billed Charges 30505952 LAB/GENERAL IMMUNOFIX ELECTRO SERUM EACH 86334 $56.00 302 $39.20 $28.00 $44.80 65% of Billed Charges 80% of Billed Charges $11.52 $11.52 $18.10 65% of Billed Charges 65% of Billed Charges 30505978 LAB/GENERAL IMMUNOFLUORESCENT GIARDIA EACH 87269 $35.00 300 $24.50 $17.50 $28.00 65% 80% 50% 50% 65% 65% 65% 31001100 LAB/GENERAL INFCT DS CHRNC HCV 6 ASSAYS EACH 81596 $181.00 310 $126.70 $90.50 $144.80 65% of Billed Charges 80% of Billed Charges $25.99 $25.99 $58.47 65% of Billed Charges 65% of Billed Charges 30515944 LAB/GENERAL INFLIXIMAB LEVEL FOR IBD EACH 80230 $97.00 305 $67.90 $48.50 $77.60 65% of Billed Charges 80% of Billed Charges $13.89 $13.89 $31.24 65% of Billed Charges 65% of Billed Charges 30506018 LAB/GENERAL INFLUENZA ANTIBODY EACH 86710 $34.00 302 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.99 $6.99 $10.98 65% of Billed Charges 65% of Billed Charges 30506067 LAB/GENERAL INSEMINATION OF OOCYTES EACH 89268 $423.00 300 $296.10 $211.50 $338.40 65% 80% 50% 50% 65% 65% 65% 30506083 LAB/GENERAL INSULIN FREE EACH 83527 $33.00 301 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.68 $6.68 $10.49 65% of Billed Charges 65% of Billed Charges 30506091 LAB/GENERAL INSULIN TOTAL EACH 83525 $29.00 301 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.90 $5.90 $9.26 65% of Billed Charges 65% of Billed Charges 30506109 LAB/GENERAL INTRINSIC FACTOR EACH 83528 $50.00 301 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $8.20 $8.20 $16.05 65% of Billed Charges 65% of Billed Charges 30506125 LAB/GENERAL IRON EACH 83540 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.24 65% of Billed Charges 65% of Billed Charges 30506133 LAB/GENERAL IRON BINDING CAPACITY EACH 83550 $22.00 301 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges $4.51 $4.51 $7.08 65% of Billed Charges 65% of Billed Charges 30506141 LAB/GENERAL IRON STAIN PERIPHERAL BLOOD EACH 85536 $18.00 305 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.57 65% of Billed Charges 65% of Billed Charges 30506166 LAB/GENERAL ISOCITRIC DEHYDROGENASE (IDH) EACH 83570 $23.00 301 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $4.56 $4.56 $7.17 65% of Billed Charges 65% of Billed Charges 30515001 LAB/GENERAL JAK2 GENE EACH 81270 $230.00 310 $161.00 $115.00 $184.00 65% of Billed Charges 80% of Billed Charges $45.02 $45.02 $74.24 65% of Billed Charges 65% of Billed Charges 30506174 LAB/GENERAL KETOGENIC STEROIDS FRACTION EACH 83582 $39.00 301 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $7.31 $7.31 $12.53 65% of Billed Charges 65% of Billed Charges 30506190 LAB/GENERAL KETOSTEROIDS (17-KS) FRAC EACH 83593 $72.00 301 $50.40 $36.00 $57.60 65% of Billed Charges 80% of Billed Charges $13.56 $13.56 $23.09 65% of Billed Charges 65% of Billed Charges 30506208 LAB/GENERAL KETOSTEROIDS (17-KS) URINE EACH 83586 $32.00 301 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.60 $6.60 $10.37 65% of Billed Charges 65% of Billed Charges 30506216 LAB/GENERAL KININOGEN ASSAY FITZGERALD EACH 85293 $48.00 305 $33.60 $24.00 $38.40 65% of Billed Charges 80% of Billed Charges $9.77 $9.77 $15.33 65% of Billed Charges 65% of Billed Charges 30510242 LAB/GENERAL KOH PREPARATION EACH Q0112 $17.00 306 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $2.20 $2.20 $4.72 65% of Billed Charges 65% of Billed Charges 30506224 LAB/GENERAL LACTATE DEHYDRO (LDH) EACH 83615 $16.00 301 $11.20 $8.00 $12.80 65% of Billed Charges 80% of Billed Charges $3.11 $3.11 $4.89 65% of Billed Charges 65% of Billed Charges 30506232 LAB/GENERAL LACTATE DEHYDRO (LDH) ISOENZ EACH 83625 $32.00 301 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.60 $6.60 $10.36 65% of Billed Charges 65% of Billed Charges 30506240 LAB/GENERAL LACTATE/LACTIC ACID BLOOD EACH 83605 $29.00 301 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.51 $5.51 $9.37 65% of Billed Charges 65% of Billed Charges 30506257 LAB/GENERAL LACTOGEN PLACENTAL EACH 83632 $51.00 301 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.42 $10.42 $16.38 65% of Billed Charges 65% of Billed Charges 30506265 LAB/GENERAL LACTOSE URINE QL EACH 83633 $29.00 301 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $2.84 $2.84 $9.11 65% of Billed Charges 65% of Billed Charges 30513105 LAB/GENERAL LEAD EACH 83655 $31.00 301 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.24 $6.24 $9.81 65% of Billed Charges 65% of Billed Charges 30506315 LAB/GENERAL LEISHMANIA ANTIBODY EACH 86717 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.32 $6.32 $9.92 65% of Billed Charges 65% of Billed Charges 30506331 LAB/GENERAL LEUCINE AMINOPEPITDASE (LAP) EACH 83670 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $4.73 $4.73 $7.95 65% of Billed Charges 65% of Billed Charges 30513113 LAB/GENERAL LEUKO ANTIBODY ID EACH 86021 $38.00 302 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.76 $7.76 $12.19 65% of Billed Charges 65% of Billed Charges 30506356 LAB/GENERAL LEUKO ASSESS FECAL QN/SEMI QN EACH 89055 $21.00 309 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $2.20 $2.20 $3.46 65% of Billed Charges 65% of Billed Charges 30506372 LAB/GENERAL LEUKOCYTE HISTAMINE RELEASE EACH 86343 $32.00 302 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.43 $6.43 $10.09 65% of Billed Charges 65% of Billed Charges 30506380 LAB/GENERAL LEUKOCYTE PHAGOCYTOSIS EACH 86344 $26.00 302 $18.20 $13.00 $20.80 65% of Billed Charges 80% of Billed Charges $4.12 $4.12 $8.42 65% of Billed Charges 65% of Billed Charges 30506406 LAB/GENERAL LIPASE EACH 83690 $18.00 301 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.55 $3.55 $5.58 65% of Billed Charges 65% of Billed Charges 30506414 LAB/GENERAL LIPID PANEL EACH 80061 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.91 $6.91 $10.85 65% of Billed Charges 65% of Billed Charges 30506422 LAB/GENERAL LIPOPROTEIN ELECTROPHOR BLD QN EACH 83700 $29.00 301 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.80 $5.80 $9.12 65% of Billed Charges 65% of Billed Charges 30506430 LAB/GENERAL LIPOPROTEIN HR FRACTION QN EACH 83701 $85.00 301 $59.50 $42.50 $68.00 65% of Billed Charges 80% of Billed Charges $12.80 $12.80 $27.43 65% of Billed Charges 65% of Billed Charges 30506448 LAB/GENERAL LISTERIA MONOCYTOGENES AB EACH 86723 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30506455 LAB/GENERAL LITHIUM EACH 80178 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.41 $3.41 $5.35 65% of Billed Charges 65% of Billed Charges 30506463 LAB/GENERAL LUTEINIZING HORMONE (LH) EACH 83002 $47.00 301 $32.90 $23.50 $37.60 65% of Billed Charges 80% of Billed Charges $9.55 $9.55 $15.00 65% of Billed Charges 65% of Billed Charges 30506471 LAB/GENERAL LUTEINIZING RELEASING FACTOR EACH 83727 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.87 $8.87 $13.92 65% of Billed Charges 65% of Billed Charges 30506497 LAB/GENERAL LYME DISEASE ANTIBODY CONFIRM EACH 86617 $39.00 302 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $7.99 $7.99 $12.55 65% of Billed Charges 65% of Billed Charges 30506505 LAB/GENERAL LYMPHOCYTE CULTURE MIXED EACH 86821 $92.00 302 $64.40 $46.00 $73.60 65% of Billed Charges 80% of Billed Charges $29.11 $29.11 $29.61 65% of Billed Charges 65% of Billed Charges 30506521 LAB/GENERAL LYMPHOCYTE TRANSFORMATION EACH 86353 $123.00 302 $86.10 $61.50 $98.40 65% of Billed Charges 80% of Billed Charges $25.28 $25.28 $39.71 65% of Billed Charges 65% of Billed Charges 30506539 LAB/GENERAL LYMPHOCYTIC CHORIOMENINGITI AB EACH 86727 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.63 $6.63 $10.42 65% of Billed Charges 65% of Billed Charges 30506547 LAB/GENERAL LYMPHOCYTOTOXICITY TITER EACH 86805 $474.00 302 $331.80 $237.00 $379.20 65% of Billed Charges 80% of Billed Charges $26.96 $26.96 $153.50 65% of Billed Charges 65% of Billed Charges 30506554 LAB/GENERAL LYMPHOCYTOTOXICITY W/O TITER EACH 86806 $119.00 302 $83.30 $59.50 $95.20 65% of Billed Charges 80% of Billed Charges $24.54 $24.54 $38.55 65% of Billed Charges 65% of Billed Charges 30506570 LAB/GENERAL MACROSCOPIC EXAM ARTHROPOD EACH 87168 $11.00 300 $7.70 $5.50 $8.80 65% 80% 50% 50% 65% 65% 65% 30506588 LAB/GENERAL MACROSCOPIC EXAM PARASITE EACH 87169 $11.00 300 $7.70 $5.50 $8.80 65% 80% 50% 50% 65% 65% 65% 30506596 LAB/GENERAL MAGNESIUM SERUM EACH 83735 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.46 $3.46 $5.43 65% of Billed Charges 65% of Billed Charges 30506612 LAB/GENERAL MALARIA ANTIBODY EACH 86750 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30506620 LAB/GENERAL MALATE DEHYDROGENASE EACH 83775 $19.00 301 $13.30 $9.50 $15.20 65% of Billed Charges 80% of Billed Charges $3.80 $3.80 $5.97 65% of Billed Charges 65% of Billed Charges 30506638 LAB/GENERAL MANGANESE BLOOD EACH 83785 $67.00 301 $46.90 $33.50 $53.60 65% of Billed Charges 80% of Billed Charges $12.68 $12.68 $21.59 65% of Billed Charges 65% of Billed Charges 30506646 LAB/GENERAL MCG CHROM INSITU 10-30 EACH 88273 $88.00 311 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $16.57 $16.57 $28.20 65% of Billed Charges 65% of Billed Charges 30506653 LAB/GENERAL MCG CHROM INSITU 3-5 EACH 88272 $102.00 311 $71.40 $51.00 $81.60 65% of Billed Charges 80% of Billed Charges $13.81 $13.81 $32.97 65% of Billed Charges 65% of Billed Charges 30506679 LAB/GENERAL MCG INTERPHASE INSITU 100-300 EACH 88275 $198.00 311 $138.60 $99.00 $158.40 65% of Billed Charges 80% of Billed Charges $20.71 $20.71 $41.46 65% of Billed Charges 65% of Billed Charges 30506687 LAB/GENERAL MCG INTERPHASE INSITU 25-99 EACH 88274 $106.00 311 $74.20 $53.00 $84.80 65% of Billed Charges 80% of Billed Charges $17.95 $17.95 $34.33 65% of Billed Charges 65% of Billed Charges 30506703 LAB/GENERAL MECHANICAL FRAGILITY RBC EACH 85547 $22.00 305 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges $4.44 $4.44 $6.97 65% of Billed Charges 65% of Billed Charges 30506711 LAB/GENERAL MEPROBAMATE EACH 80369 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $8.63 $8.63 $0.01 65% of Billed Charges 65% of Billed Charges 30506729 LAB/GENERAL MERCURY BLOOD EACH 83825 $41.00 301 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $8.38 $8.38 $13.17 65% of Billed Charges 65% of Billed Charges 30506760 LAB/GENERAL METHADONE EACH 80358 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $8.00 $8.00 $0.01 65% of Billed Charges 65% of Billed Charges 30506778 LAB/GENERAL METHEMALBUMIN EACH 83857 $27.00 301 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $5.54 $5.54 $8.70 65% of Billed Charges 65% of Billed Charges 30506786 LAB/GENERAL METHEMOGLOBIN QL EACH 83045 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $2.56 $2.56 $5.26 65% of Billed Charges 65% of Billed Charges 30506794 LAB/GENERAL METHEMOGLOBIN QN EACH 83050 $21.00 301 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $3.78 $3.78 $6.64 65% of Billed Charges 65% of Billed Charges 30516439 LAB/GENERAL METHOTREXATE EACH 80204 $97.00 300 $67.90 $48.50 $77.60 65% 80% 50% 50% 65% 65% 65% 30506810 LAB/GENERAL METYRAPONE PANEL EACH 80436 $228.00 301 $159.60 $114.00 $182.40 65% of Billed Charges 80% of Billed Charges $47.00 $47.00 $73.84 65% of Billed Charges 65% of Billed Charges 30506828 LAB/GENERAL MICROALBUMIN URINE QN EACH 82043 $15.00 301 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $2.98 $2.98 $4.68 65% of Billed Charges 65% of Billed Charges 30506836 LAB/GENERAL MICROALBUMIN URINE SQ EACH 82044 $16.00 301 $11.20 $8.00 $12.80 65% of Billed Charges 80% of Billed Charges $2.36 $2.36 $5.05 65% of Billed Charges 65% of Billed Charges 30506844 LAB/GENERAL MICROBIOLOGY UNLSTD PROC EACH 87999 $99.00 306 $69.30 $49.50 $79.20 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 30506869 LAB/GENERAL MICROSOMAL ANTIBODY THYROID EACH 86376 $37.00 302 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.50 $7.50 $11.79 65% of Billed Charges 65% of Billed Charges 30506885 LAB/GENERAL MOLEC DX PRIOR NUC EXTRACTION EACH 81200 $119.00 310 $83.30 $59.50 $95.20 65% of Billed Charges 80% of Billed Charges $17.01 $17.01 $38.27 65% of Billed Charges 65% of Billed Charges 30516124 LAB/GENERAL MOLECULAR PATHOLOGY PROC NOS EACH 81479 $450.00 300 $315.00 $225.00 $360.00 65% 80% 50% 50% 65% 65% 65% 30507032 LAB/GENERAL MONONUCLEAR CELL ANTIGEN QN EACH 86356 $67.00 302 $46.90 $33.50 $53.60 65% of Billed Charges 80% of Billed Charges $13.81 $13.81 $21.69 65% of Billed Charges 65% of Billed Charges 30512297 LAB/GENERAL MOPATH PROCEDURE LEVEL 2 EACH 81401 $343.00 310 $240.10 $171.50 $274.40 65% of Billed Charges 80% of Billed Charges $49.32 $49.32 $110.97 65% of Billed Charges 65% of Billed Charges 30507040 LAB/GENERAL MUCIN CLOT SYNOVIAL FLUID EACH 83872 $15.00 301 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $3.02 $3.02 $4.75 65% of Billed Charges 65% of Billed Charges 30507057 LAB/GENERAL MUCOPOLYSACCHARIDES QN EACH 83864 $72.00 301 $50.40 $36.00 $57.60 65% of Billed Charges 80% of Billed Charges $10.26 $10.26 $23.09 65% of Billed Charges 65% of Billed Charges 30507073 LAB/GENERAL MUCORMYCOSIS ANTIBODY EACH 86732 $38.00 302 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $12.15 65% of Billed Charges 65% of Billed Charges 30513139 LAB/GENERAL MUMPS ANTIBODY EACH 86735 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.73 $6.73 $10.57 65% of Billed Charges 65% of Billed Charges 30507156 LAB/GENERAL MYCOPLASMA ANTIBODY EACH 86738 $34.00 302 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.83 $6.83 $10.72 65% of Billed Charges 65% of Billed Charges 30507198 LAB/GENERAL MYELIN BASIC PROTEIN (CSF) EACH 83873 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.87 $8.87 $13.93 65% of Billed Charges 65% of Billed Charges 30507214 LAB/GENERAL MYOGLOBIN URINE EACH 83874 $33.00 301 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.66 $6.66 $10.47 65% of Billed Charges 65% of Billed Charges 30507222 LAB/GENERAL NATRIURETIC PEPTIDE EACH 83880 $99.00 301 $69.30 $49.50 $79.20 65% of Billed Charges 80% of Billed Charges $17.50 $17.50 $31.80 65% of Billed Charges 65% of Billed Charges 30507230 LAB/GENERAL NATURAL KILLER CELLS TOTAL EACH 86357 $95.00 302 $66.50 $47.50 $76.00 65% of Billed Charges 80% of Billed Charges $19.45 $19.45 $30.56 65% of Billed Charges 65% of Billed Charges 30507248 LAB/GENERAL NEISSERIA MENINGITIDIS AB EACH 86741 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30507263 LAB/GENERAL NEUTRALIZATION VIRAL EACH 86382 $43.00 302 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.72 $8.72 $13.70 65% of Billed Charges 65% of Billed Charges 30507289 LAB/GENERAL NICKEL URINE EACH 83885 $62.00 301 $43.40 $31.00 $49.60 65% of Billed Charges 80% of Billed Charges $12.63 $12.63 $19.85 65% of Billed Charges 65% of Billed Charges 30507305 LAB/GENERAL NITROBLUE TETRAZOLIUM DYE EACH 86384 $35.00 302 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $5.87 $5.87 $11.02 65% of Billed Charges 65% of Billed Charges 30507339 LAB/GENERAL NUC ACID STAPH A AMPLIFIED EACH 87640 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507347 LAB/GENERAL NUC ACID STPH AUREUS AMPLIFIED EACH 87641 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507354 LAB/GENERAL NUCLEIC ACID AMP BARTONELLA EACH 87471 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507362 LAB/GENERAL NUCLEIC ACID AMP BORRELIA EACH 87476 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507370 LAB/GENERAL NUCLEIC ACID AMP CANDIDA EACH 87481 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507388 LAB/GENERAL NUCLEIC ACID AMP CMV EACH 87496 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507396 LAB/GENERAL NUCLEIC ACID AMP ENTEROVIRUS EACH 87498 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507404 LAB/GENERAL NUCLEIC ACID AMP GARDNERELLA EACH 87511 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507420 LAB/GENERAL NUCLEIC ACID AMP HEPATITIS C EACH 87521 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507438 LAB/GENERAL NUCLEIC ACID AMP HEPATITIS G EACH 87526 $99.00 306 $69.30 $49.50 $79.20 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $31.80 65% of Billed Charges 65% of Billed Charges 30507446 LAB/GENERAL NUCLEIC ACID AMP HERPES 6 EACH 87532 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507453 LAB/GENERAL NUCLEIC ACID AMP HERPES SMPX EACH 87529 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30512867 LAB/GENERAL NUCLEIC ACID AMP INFECTIOUS 1 EACH 87798 $88.00 300 $61.60 $44.00 $70.40 65% 80% 50% 50% 65% 65% 65% 30507479 LAB/GENERAL NUCLEIC ACID AMP LEGIONELLA EACH 87541 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507487 LAB/GENERAL NUCLEIC ACID AMP MLT ORG EACH 87801 $176.00 306 $123.20 $88.00 $140.80 65% of Billed Charges 80% of Billed Charges $36.19 $36.19 $56.86 65% of Billed Charges 65% of Billed Charges 30507495 LAB/GENERAL NUCLEIC ACID AMP MYCOBACT AI EACH 87561 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507503 LAB/GENERAL NUCLEIC ACID AMP MYCOBACT SP EACH 87551 $121.00 306 $84.70 $60.50 $96.80 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $39.07 65% of Billed Charges 65% of Billed Charges 30507511 LAB/GENERAL NUCLEIC ACID AMP MYCOP PNEUM EACH 87581 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507529 LAB/GENERAL NUCLEIC ACID AMP NEISSERIA EACH 87591 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507545 LAB/GENERAL NUCLEIC ACID AMP PROBE HIV-2 EACH 87538 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507560 LAB/GENERAL NUCLEIC ACID AMP STREP A EACH 87651 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507578 LAB/GENERAL NUCLEIC ACID AMP TB EACH 87556 $105.00 306 $73.50 $52.50 $84.00 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $33.76 65% of Billed Charges 65% of Billed Charges 30507586 LAB/GENERAL NUCLEIC ACID CHLAMYDIA PNEUM EACH 87486 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507594 LAB/GENERAL NUCLEIC ACID CHLAMYDIA TRACH EACH 87491 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507610 LAB/GENERAL NUCLEIC ACID DIRECT BORRELIA EACH 87475 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30507628 LAB/GENERAL NUCLEIC ACID DIRECT CANDIDA EACH 87480 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30507644 LAB/GENERAL NUCLEIC ACID DIRECT GARDNERELL EACH 87510 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30507651 LAB/GENERAL NUCLEIC ACID DIRECT GC EACH 87590 $68.00 306 $47.60 $34.00 $54.40 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $21.77 65% of Billed Charges 65% of Billed Charges 30507677 LAB/GENERAL NUCLEIC ACID DIRECT HEPA C EACH 87520 $79.00 306 $55.30 $39.50 $63.20 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $25.29 65% of Billed Charges 65% of Billed Charges 30507685 LAB/GENERAL NUCLEIC ACID DIRECT HEPA G EACH 87525 $75.00 306 $52.50 $37.50 $60.00 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $24.14 65% of Billed Charges 65% of Billed Charges 30507693 LAB/GENERAL NUCLEIC ACID DIRECT HERPE SMPX EACH 87528 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30507701 LAB/GENERAL NUCLEIC ACID DIRECT HERPES 6 EACH 87531 $145.00 306 $101.50 $72.50 $116.00 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $46.98 65% of Billed Charges 65% of Billed Charges 30507719 LAB/GENERAL NUCLEIC ACID DIRECT HIV-1 EACH 87534 $55.00 306 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $17.76 65% of Billed Charges 65% of Billed Charges 30507727 LAB/GENERAL NUCLEIC ACID DIRECT HIV-2 EACH 87537 $55.00 306 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $17.76 65% of Billed Charges 65% of Billed Charges 30507735 LAB/GENERAL NUCLEIC ACID DIRECT HPV EACH 87624 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $17.19 $17.19 $28.42 65% of Billed Charges 65% of Billed Charges 30507750 LAB/GENERAL NUCLEIC ACID DIRECT LEGIONELLA EACH 87540 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30507768 LAB/GENERAL NUCLEIC ACID DIRECT MLT ORG EACH 87800 $110.00 306 $77.00 $55.00 $88.00 65% of Billed Charges 80% of Billed Charges $20.68 $20.68 $35.37 65% of Billed Charges 65% of Billed Charges 30507776 LAB/GENERAL NUCLEIC ACID DIRECT MYCOBACT A EACH 87560 $69.00 306 $48.30 $34.50 $55.20 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $22.10 65% of Billed Charges 65% of Billed Charges 30507784 LAB/GENERAL NUCLEIC ACID DIRECT MYCOBACT S EACH 87550 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30507792 LAB/GENERAL NUCLEIC ACID DIRECT MYCOPLASMA EACH 87580 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30507800 LAB/GENERAL NUCLEIC ACID DIRECT STREP A EACH 87650 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30507818 LAB/GENERAL NUCLEIC ACID DIRECT TB EACH 87555 $68.00 306 $47.60 $34.00 $54.40 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $21.77 65% of Billed Charges 65% of Billed Charges 30507826 LAB/GENERAL NUCLEIC ACID DRCT CHLAMY PNEUM EACH 87485 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30507834 LAB/GENERAL NUCLEIC ACID DRCT CHLAMY TRACH EACH 87490 $57.00 306 $39.90 $28.50 $45.60 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $18.43 65% of Billed Charges 65% of Billed Charges 30507842 LAB/GENERAL NUCLEIC ACID GENOTYPE HEP C EACH 87902 $644.00 306 $450.80 $322.00 $515.20 65% of Billed Charges 80% of Billed Charges $132.74 $132.74 $208.53 65% of Billed Charges 65% of Billed Charges 30507859 LAB/GENERAL NUCLEIC ACID GENOTYPE HIV 1 EACH 87901 $644.00 306 $450.80 $322.00 $515.20 65% of Billed Charges 80% of Billed Charges $132.74 $132.74 $208.53 65% of Billed Charges 65% of Billed Charges 30507867 LAB/GENERAL NUCLEIC ACID HIV 1 1-10 DRUGS EACH 87903 "$1,222.00 " 306 $855.40 $611.00 $977.60 65% of Billed Charges 80% of Billed Charges $251.96 $251.96 $395.81 65% of Billed Charges 65% of Billed Charges 30507875 LAB/GENERAL NUCLEIC ACID HIV 1 EA ADD DRUG EACH 87904 $66.00 306 $46.20 $33.00 $52.80 65% of Billed Charges 80% of Billed Charges $13.44 $13.44 $21.12 65% of Billed Charges 65% of Billed Charges 30507883 LAB/GENERAL NUCLEIC ACID QN BARTONELLA EACH 87472 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30507909 LAB/GENERAL NUCLEIC ACID QN CANDIDA EACH 87482 $140.00 306 $98.00 $70.00 $112.00 65% of Billed Charges 80% of Billed Charges $21.52 $21.52 $45.15 65% of Billed Charges 65% of Billed Charges 30507917 LAB/GENERAL NUCLEIC ACID QN CHLAMY TRACH EACH 87492 $134.00 306 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $18.03 $18.03 $43.31 65% of Billed Charges 65% of Billed Charges 30507925 LAB/GENERAL NUCLEIC ACID QN CHLAMYPNEUM EACH 87487 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30507941 LAB/GENERAL NUCLEIC ACID QN GARDNERELLA EACH 87512 $105.00 306 $73.50 $52.50 $84.00 65% of Billed Charges 80% of Billed Charges $21.52 $21.52 $33.83 65% of Billed Charges 65% of Billed Charges 30507958 LAB/GENERAL NUCLEIC ACID QN GC EACH 87592 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30507966 LAB/GENERAL NUCLEIC ACID QN HEPATITIS B EACH 87517 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30507974 LAB/GENERAL NUCLEIC ACID QN HEPATITIS C EACH 87522 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30507982 LAB/GENERAL NUCLEIC ACID QN HEPATITIS G EACH 87527 $105.00 306 $73.50 $52.50 $84.00 65% of Billed Charges 80% of Billed Charges $21.52 $21.52 $33.83 65% of Billed Charges 65% of Billed Charges 30507990 LAB/GENERAL NUCLEIC ACID QN HERPES 6 EACH 87533 $105.00 306 $73.50 $52.50 $84.00 65% of Billed Charges 80% of Billed Charges $21.52 $21.52 $33.83 65% of Billed Charges 65% of Billed Charges 30508006 LAB/GENERAL NUCLEIC ACID QN HERPES SMPX EACH 87530 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30508014 LAB/GENERAL NUCLEIC ACID QN HIV-1 EACH 87536 $213.00 306 $149.10 $106.50 $170.40 65% of Billed Charges 80% of Billed Charges $43.88 $43.88 $68.93 65% of Billed Charges 65% of Billed Charges 30508022 LAB/GENERAL NUCLEIC ACID QN HIV-2 EACH 87539 $147.00 306 $102.90 $73.50 $117.60 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $47.48 65% of Billed Charges 65% of Billed Charges 30508048 LAB/GENERAL NUCLEIC ACID QN INFECT AGENT EACH 87799 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30508055 LAB/GENERAL NUCLEIC ACID QN LEGIONELLA EACH 87542 $105.00 306 $73.50 $52.50 $84.00 65% of Billed Charges 80% of Billed Charges $21.52 $21.52 $33.83 65% of Billed Charges 65% of Billed Charges 30508063 LAB/GENERAL NUCLEIC ACID QN MYCOBACT AI EACH 87562 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30508071 LAB/GENERAL NUCLEIC ACID QN MYCOBACT SP EACH 87552 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30508089 LAB/GENERAL NUCLEIC ACID QN MYCOP PNEUM EACH 87582 $757.00 306 $529.90 $378.50 $605.60 65% of Billed Charges 80% of Billed Charges $21.52 $21.52 $245.12 65% of Billed Charges 65% of Billed Charges 30508097 LAB/GENERAL NUCLEIC ACID QN STREP A EACH 87652 $105.00 306 $73.50 $52.50 $84.00 65% of Billed Charges 80% of Billed Charges $21.52 $21.52 $33.83 65% of Billed Charges 65% of Billed Charges 30508105 LAB/GENERAL NUCLEIC ACID QN TB EACH 87557 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30508113 LAB/GENERAL NUCLEIC ACID QN TRICHOMON EACH 87660 $51.00 306 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $16.24 65% of Billed Charges 65% of Billed Charges 30508121 LAB/GENERAL NUCLEIC ACID STREP GROUP B EACH 87653 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30508139 LAB/GENERAL NUCLEIC ACID VANCOMYCIN RESIST EACH 87500 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30508147 LAB/GENERAL NUCLEOTIDASE 5 EACH 83915 $28.00 301 $19.60 $14.00 $22.40 65% of Billed Charges 80% of Billed Charges $5.75 $5.75 $9.03 65% of Billed Charges 65% of Billed Charges 30508154 LAB/GENERAL OBSTETRIC PANEL EACH 80055 $120.00 300 $84.00 $60.00 $96.00 65% 80% 50% 50% 65% 65% 65% 30508162 LAB/GENERAL OCCULT BLD QL OTHER SOURCES EACH 82271 $14.00 301 $9.80 $7.00 $11.20 65% of Billed Charges 80% of Billed Charges $1.68 $1.68 $4.31 65% of Billed Charges 65% of Billed Charges 30508170 LAB/GENERAL OCCULT BLOOD FECES SCREEN EACH 82270 $11.00 301 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $1.68 $1.68 $3.55 65% of Billed Charges 65% of Billed Charges 30508196 LAB/GENERAL ONCOPROTEIN HER-2/NEU EACH 83950 $162.00 301 $113.40 $81.00 $129.60 65% of Billed Charges 80% of Billed Charges $33.21 $33.21 $52.17 65% of Billed Charges 65% of Billed Charges 30508204 LAB/GENERAL OOCYTE ID EACH 89254 $423.00 309 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $391.40 65% of Billed Charges 65% of Billed Charges 30508220 LAB/GENERAL ORGANIC ACIDS TOTAL QN EACH 83918 $59.00 301 $41.30 $29.50 $47.20 65% of Billed Charges 80% of Billed Charges $8.49 $8.49 $19.12 65% of Billed Charges 65% of Billed Charges 30511596 LAB/GENERAL "ORGANIC ACIDS, EA SPECIMEN " EACH 83919 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.49 $8.49 $13.32 65% of Billed Charges 65% of Billed Charges 30508238 LAB/GENERAL OSMOLALITY BLOOD EACH 83930 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.41 $3.41 $5.35 65% of Billed Charges 65% of Billed Charges 30508246 LAB/GENERAL OSMOLALITY URINE EACH 83935 $18.00 301 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.51 $3.51 $5.52 65% of Billed Charges 65% of Billed Charges 30508253 LAB/GENERAL OSMOTIC FRAGILITY RBC INCUBATE EACH 85557 $34.00 305 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.89 $6.89 $10.82 65% of Billed Charges 65% of Billed Charges 30508279 LAB/GENERAL OSTEOCALCIN EACH 83937 $75.00 301 $52.50 $37.50 $60.00 65% of Billed Charges 80% of Billed Charges $15.39 $15.39 $24.18 65% of Billed Charges 65% of Billed Charges 30508287 LAB/GENERAL OXALATE BLOOD EACH 83945 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $6.64 $6.64 $11.70 65% of Billed Charges 65% of Billed Charges 30508311 LAB/GENERAL PARATHORMONE (PT/H) C TERMINAL EACH 83970 $104.00 301 $72.80 $52.00 $83.20 65% of Billed Charges 80% of Billed Charges $21.28 $21.28 $33.44 65% of Billed Charges 65% of Billed Charges 30508337 LAB/GENERAL PARTIAL THROMBOPLAS TIME (PTT) EACH 85730 $16.00 305 $11.20 $8.00 $12.80 65% of Billed Charges 80% of Billed Charges $3.10 $3.10 $4.87 65% of Billed Charges 65% of Billed Charges 30508360 LAB/GENERAL PARTICLE AGG SCREEN EACH 86403 $29.00 302 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.26 $5.26 $9.35 65% of Billed Charges 65% of Billed Charges 30508386 LAB/GENERAL PARVOVIRUS ANTIBODY EACH 86747 $38.00 302 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.75 $7.75 $12.17 65% of Billed Charges 65% of Billed Charges 30511109 LAB/GENERAL PATH - PROSTATE NEEDLE BIOPSY EACH G0416 $889.00 314 $622.30 $444.50 $711.20 65% of Billed Charges 80% of Billed Charges $126.00 $126.00 $342.35 65% of Billed Charges 65% of Billed Charges 30508428 LAB/GENERAL PH BODY FLUID EACH 83986 $9.00 301 $6.30 $4.50 $7.20 65% of Billed Charges 80% of Billed Charges $1.85 $1.85 $2.90 65% of Billed Charges 65% of Billed Charges 30508436 LAB/GENERAL PHENCYCLIDINE (PCP) EACH 83992 $73.00 301 $51.10 $36.50 $58.40 65% of Billed Charges 80% of Billed Charges $7.58 $7.58 $0.01 65% of Billed Charges 65% of Billed Charges 30508444 LAB/GENERAL PHENOBARBITAL EACH 80184 $39.00 301 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $5.91 $5.91 $12.39 65% of Billed Charges 65% of Billed Charges 30508451 LAB/GENERAL PHENOTHIAZINE EACH 80342 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $7.63 $7.63 $0.01 65% of Billed Charges 65% of Billed Charges 30508469 LAB/GENERAL PHENYLALANINE (PKU) EACH 84030 $14.00 301 $9.80 $7.00 $11.20 65% of Billed Charges 80% of Billed Charges $2.84 $2.84 $4.46 65% of Billed Charges 65% of Billed Charges 30508477 LAB/GENERAL PHENYLKETONES EACH 84035 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $1.89 $1.89 $3.22 65% of Billed Charges 65% of Billed Charges 30508485 LAB/GENERAL PHENYTOIN (DILANTIN) FREE EACH 80186 $35.00 301 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.10 $7.10 $11.15 65% of Billed Charges 65% of Billed Charges 30508493 LAB/GENERAL PHENYTOIN (DILANTIN) TOTAL EACH 80185 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.84 $6.84 $10.73 65% of Billed Charges 65% of Billed Charges 30508501 LAB/GENERAL PHOSPHATASE ACID EACH 84060 $20.00 301 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $3.81 $3.81 $6.19 65% of Billed Charges 65% of Billed Charges 30508519 LAB/GENERAL PHOSPHATASE ACID PROSTATIC EACH 84066 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $4.98 $4.98 $7.82 65% of Billed Charges 65% of Billed Charges 30513147 LAB/GENERAL PHOSPHATASE ALKALINE EACH 84075 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.67 $2.67 $4.20 65% of Billed Charges 65% of Billed Charges 30508535 LAB/GENERAL PHOSPHATASE ALKALINE HEAT EACH 84078 $21.00 301 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $3.77 $3.77 $6.69 65% of Billed Charges 65% of Billed Charges 30508543 LAB/GENERAL PHOSPHATASE ALKALINE ISOENZYME EACH 84080 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.63 $7.63 $11.97 65% of Billed Charges 65% of Billed Charges 30508568 LAB/GENERAL PHOSPHOGLUCONATE 6-D RBC EACH 84085 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $3.48 $3.48 $7.65 65% of Billed Charges 65% of Billed Charges 30508576 LAB/GENERAL PHOSPHOHEXOSE ISOMERASE EACH 84087 $27.00 301 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $5.32 $5.32 $8.69 65% of Billed Charges 65% of Billed Charges 30508584 LAB/GENERAL PHOSPHORUS BLOOD EACH 84100 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.44 $2.44 $3.84 65% of Billed Charges 65% of Billed Charges 30508592 LAB/GENERAL PHOSPHORUS URINE EACH 84105 $15.00 301 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $2.67 $2.67 $4.68 65% of Billed Charges 65% of Billed Charges 30508600 LAB/GENERAL PINWORM EXAM EACH 87172 $11.00 300 $7.70 $5.50 $8.80 65% 80% 50% 50% 65% 65% 65% 30508618 LAB/GENERAL PLASMINOGEN ACTIVATOR EACH 85415 $43.00 305 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.87 $8.87 $13.92 65% of Billed Charges 65% of Billed Charges 30508626 LAB/GENERAL PLASMINOGEN ANTIGENIC EACH 85421 $26.00 305 $18.20 $13.00 $20.80 65% of Billed Charges 80% of Billed Charges $5.25 $5.25 $8.25 65% of Billed Charges 65% of Billed Charges 30508634 LAB/GENERAL PLASMINOGEN NONANTIGENIC EACH 85420 $17.00 305 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.37 $3.37 $5.29 65% of Billed Charges 65% of Billed Charges 30508642 LAB/GENERAL PLATELET AGGREGATION EA EACH 85576 $63.00 305 $44.10 $31.50 $50.40 65% of Billed Charges 80% of Billed Charges $11.08 $11.08 $20.18 65% of Billed Charges 65% of Billed Charges 30513154 LAB/GENERAL PLATELET ANTIBODY ID EACH 86022 $46.00 302 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $9.47 $9.47 $14.88 65% of Billed Charges 65% of Billed Charges 30508667 LAB/GENERAL PLATELET ASSOC ANTIBODY ID EACH 86023 $32.00 302 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.42 $6.42 $10.09 65% of Billed Charges 65% of Billed Charges 30508675 LAB/GENERAL PLATELET COUNT MANUAL EACH 85032 $11.00 305 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $2.22 $2.22 $3.49 65% of Billed Charges 65% of Billed Charges 30508683 LAB/GENERAL POLIOVIRUS ANTIBODY EACH 86658 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.72 $6.72 $10.55 65% of Billed Charges 65% of Billed Charges 30508709 LAB/GENERAL PORPHOBILINOGEN URINE QN EACH 84110 $22.00 301 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges $4.36 $4.36 $6.84 65% of Billed Charges 65% of Billed Charges 30508717 LAB/GENERAL PORPHYRINS FECES QN EACH 84126 $98.00 301 $68.60 $49.00 $78.40 65% of Billed Charges 80% of Billed Charges $13.13 $13.13 $31.68 65% of Billed Charges 65% of Billed Charges 30508741 LAB/GENERAL POTASSIUM SERUM EACH 84132 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.37 $2.37 $3.86 65% of Billed Charges 65% of Billed Charges 30508758 LAB/GENERAL POTASSIUM URINE EACH 84133 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.22 $2.22 $3.83 65% of Billed Charges 65% of Billed Charges 30508766 LAB/GENERAL PREALBUMIN EACH 84134 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.52 $7.52 $11.82 65% of Billed Charges 65% of Billed Charges 30508774 LAB/GENERAL PREGNANEDIOL EACH 84135 $54.00 301 $37.80 $27.00 $43.20 65% of Billed Charges 80% of Billed Charges $9.86 $9.86 $17.23 65% of Billed Charges 65% of Billed Charges 30508782 LAB/GENERAL PREGNANETRIOL EACH 84138 $53.00 301 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $9.76 $9.76 $17.05 65% of Billed Charges 65% of Billed Charges 30508790 LAB/GENERAL PREKALLIKREIN ASSAY FLETCHER EACH 85292 $48.00 305 $33.60 $24.00 $38.40 65% of Billed Charges 80% of Billed Charges $9.77 $9.77 $15.33 65% of Billed Charges 65% of Billed Charges 30508824 LAB/GENERAL PROGESTERONE EACH 84144 $53.00 301 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $10.76 $10.76 $16.90 65% of Billed Charges 65% of Billed Charges 30508840 LAB/GENERAL PROLACTIN EACH 84146 $49.00 301 $34.30 $24.50 $39.20 65% of Billed Charges 80% of Billed Charges $9.99 $9.99 $15.70 65% of Billed Charges 65% of Billed Charges 30508865 LAB/GENERAL PROSTAGLANDIN EACH 84150 $105.00 301 $73.50 $52.50 $84.00 65% of Billed Charges 80% of Billed Charges $12.87 $12.87 $33.83 65% of Billed Charges 65% of Billed Charges 30513162 LAB/GENERAL PROSTATE SPECIFIC AG TOTAL EACH 84153 $46.00 301 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $9.48 $9.48 $14.90 65% of Billed Charges 65% of Billed Charges 30508899 LAB/GENERAL PROTEIN C ACTIVITY EACH 85303 $35.00 305 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.13 $7.13 $11.21 65% of Billed Charges 65% of Billed Charges 30513170 LAB/GENERAL PROTEIN C ANTIGEN EACH 85302 $31.00 305 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.20 $6.20 $9.73 65% of Billed Charges 65% of Billed Charges 30508915 LAB/GENERAL PROTEIN ELECTROPHORESIS SERUM EACH 84165 $27.00 301 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $5.54 $5.54 $8.70 65% of Billed Charges 65% of Billed Charges 30508923 LAB/GENERAL PROTEIN ELECTROPHORESIS UR CSF EACH 84166 $45.00 301 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.19 $9.19 $14.44 65% of Billed Charges 65% of Billed Charges 30508931 LAB/GENERAL PROTEIN S FREE EACH 85306 $39.00 305 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $7.90 $7.90 $12.41 65% of Billed Charges 65% of Billed Charges 30508956 LAB/GENERAL PROTEIN TOTAL CSF OTHER SOURCE EACH 84157 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $1.89 $1.89 $3.24 65% of Billed Charges 65% of Billed Charges 30508964 LAB/GENERAL PROTEIN TOTAL REFRACTOMETRIC EACH 84160 $15.00 301 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $2.67 $2.67 $4.54 65% of Billed Charges 65% of Billed Charges 30513188 LAB/GENERAL PROTEIN TOTAL SERUM EACH 84155 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $1.89 $1.89 $2.97 65% of Billed Charges 65% of Billed Charges 30508980 LAB/GENERAL PROTEIN TOTAL URINE EACH 84156 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $1.89 $1.89 $2.97 65% of Billed Charges 65% of Billed Charges 30508998 LAB/GENERAL PROTEIN WESTERN BLOT EACH 84181 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.78 $8.78 $13.79 65% of Billed Charges 65% of Billed Charges 30509012 LAB/GENERAL PROTHROMBIN TIME (PT) EACH 85610 $11.00 305 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $2.02 $2.02 $3.47 65% of Billed Charges 65% of Billed Charges 30509038 LAB/GENERAL PROTOPORPHYRIN SCREEN EACH 84203 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $4.44 $4.44 $7.89 65% of Billed Charges 65% of Billed Charges 30509053 LAB/GENERAL PT/OT SUBSTITUTION EACH 85732 $17.00 305 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.24 65% of Billed Charges 65% of Billed Charges 30509087 LAB/GENERAL PYRUVATE KINASE EACH 84220 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $4.86 $4.86 $7.65 65% of Billed Charges 65% of Billed Charges 30509103 LAB/GENERAL QUININE EACH 84228 $30.00 301 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.00 $6.00 $9.42 65% of Billed Charges 65% of Billed Charges 30514491 LAB/GENERAL RAPID COVID SURVEILLANCE-BINAX EACH 87811 $104.00 310 $72.80 $52.00 $83.20 65% of Billed Charges 80% of Billed Charges $14.93 $14.93 $41.38 65% of Billed Charges 65% of Billed Charges 30509145 LAB/GENERAL RECEPT/OR ASSAY ENDOCRINE EACH 84235 $179.00 301 $125.30 $89.50 $143.20 65% of Billed Charges 80% of Billed Charges $26.99 $26.99 $57.70 65% of Billed Charges 65% of Billed Charges 30509137 LAB/GENERAL RECEPTOR ASSAY ACETYLCHOLINE EACH 84238 $92.00 301 $64.40 $46.00 $73.60 65% of Billed Charges 80% of Billed Charges $18.86 $18.86 $29.62 65% of Billed Charges 65% of Billed Charges 30509152 LAB/GENERAL RECEPTOR ASSAY ESTROGEN EACH 84233 $220.00 301 $154.00 $110.00 $176.00 65% of Billed Charges 80% of Billed Charges $33.21 $33.21 $71.18 65% of Billed Charges 65% of Billed Charges 30509178 LAB/GENERAL RECEPTOR ASSAY PROGESTERONE EACH 84234 $163.00 301 $114.10 $81.50 $130.40 65% of Billed Charges 80% of Billed Charges $33.45 $33.45 $52.55 65% of Billed Charges 65% of Billed Charges 30509186 LAB/GENERAL RENAL FUNCTION PANEL EACH 80069 $22.00 301 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges $4.47 $4.47 $7.03 65% of Billed Charges 65% of Billed Charges 30509202 LAB/GENERAL REPTILASE TEST EACH 85635 $25.00 305 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $5.08 $5.08 $7.98 65% of Billed Charges 65% of Billed Charges 30513519 LAB/GENERAL RESP VIRUS 3-5 TARGETS EACH 87631 $357.00 306 $249.90 $178.50 $285.60 65% of Billed Charges 80% of Billed Charges $63.48 $63.48 $115.53 65% of Billed Charges 65% of Billed Charges 30509228 LAB/GENERAL RHEUMATOID FACTOR QL BLOOD EACH 86430 $16.00 302 $11.20 $8.00 $12.80 65% of Billed Charges 80% of Billed Charges $2.93 $2.93 $4.97 65% of Billed Charges 65% of Billed Charges 30509236 LAB/GENERAL RHEUMATOID FACTOR QN EACH 86431 $15.00 302 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $2.93 $2.93 $4.59 65% of Billed Charges 65% of Billed Charges 30509244 LAB/GENERAL RICKETTSIA ANTIBODY EACH 86757 $49.00 302 $34.30 $24.50 $39.20 65% of Billed Charges 80% of Billed Charges $9.98 $9.98 $15.67 65% of Billed Charges 65% of Billed Charges 30513246 LAB/GENERAL RL-17 OH PREGNENOLONE EACH 84143 $58.00 301 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges $11.77 $11.77 $18.48 65% of Billed Charges 65% of Billed Charges 30500045 LAB/GENERAL RL-ACETONE KETONES SERUM QN EACH 82010 $21.00 301 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $4.22 $4.22 $6.62 65% of Billed Charges 65% of Billed Charges 30500102 LAB/GENERAL RL-ADENOVIRUS ANTIBODY EACH 86603 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.63 $6.63 $10.42 65% of Billed Charges 65% of Billed Charges 30500110 LAB/GENERAL RL-ADRENOCORTICOTROPIC (ACTH) EACH 82024 $97.00 301 $67.90 $48.50 $77.60 65% of Billed Charges 80% of Billed Charges $19.92 $19.92 $31.28 65% of Billed Charges 65% of Billed Charges 30500169 LAB/GENERAL RL-ALBUMIN SERUM EACH 82040 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.55 $2.55 $4.01 65% of Billed Charges 65% of Billed Charges 30500219 LAB/GENERAL RL-ALDOLASE EACH 82085 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $5.00 $5.00 $7.87 65% of Billed Charges 65% of Billed Charges 30500300 LAB/GENERAL RL-ALPHA-1 ANTITRYPSIN TOTAL EACH 82103 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.93 $6.93 $10.89 65% of Billed Charges 65% of Billed Charges 30515936 LAB/GENERAL RL-ALPHA-GLOB COMMON MUTAT ANA EACH 81257 $256.00 305 $179.20 $128.00 $204.80 65% of Billed Charges 80% of Billed Charges $36.81 $36.81 $82.83 65% of Billed Charges 65% of Billed Charges 30511521 LAB/GENERAL RL-AMINO ACIDS QUAN 6 OR MORE EACH 82139 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.70 $8.70 $13.66 65% of Billed Charges 65% of Billed Charges 30516462 LAB/GENERAL RL-AMIODARONE EACH 80151 $47.00 301 $32.90 $23.50 $37.60 65% of Billed Charges 80% of Billed Charges $6.71 $6.71 Non Payable 65% of Billed Charges 65% of Billed Charges 30514368 LAB/GENERAL RL-AML DNA GENOTYPING TANDEM EACH 0023U $622.00 310 $435.40 $311.00 $497.60 65% of Billed Charges 80% of Billed Charges $89.46 $89.46 $201.29 65% of Billed Charges 65% of Billed Charges 30500490 LAB/GENERAL RL-ANDROSTENEDIONE EACH 82157 $74.00 301 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $15.09 $15.09 $23.72 65% of Billed Charges 65% of Billed Charges 30512719 LAB/GENERAL RL-ANTIBDY JOHN CUNNINGHAM VIR EACH 86711 $43.00 300 $30.10 $21.50 $34.40 65% 80% 50% 50% 65% 65% 65% 30500565 LAB/GENERAL RL-ANTISTREPTOLYSIN O TITER EACH 86060 $19.00 302 $13.30 $9.50 $15.20 65% of Billed Charges 80% of Billed Charges $3.77 $3.77 $5.91 65% of Billed Charges 65% of Billed Charges 30500573 LAB/GENERAL RL-ANTITHROMBIN III ACTIVITY EACH 85300 $30.00 305 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.11 $6.11 $9.60 65% of Billed Charges 65% of Billed Charges 30516587 LAB/GENERAL RL-AQUAPORIN-4 ANTB ELISA EACH 86596 $31.00 301 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.62 Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 30500607 LAB/GENERAL RL-ARSENIC BLOOD EACH 82175 $48.00 301 $33.60 $24.00 $38.40 65% of Billed Charges 80% of Billed Charges $9.78 $9.78 $15.37 65% of Billed Charges 65% of Billed Charges 30512628 LAB/GENERAL RL-ASSAY OF G6PD ENZYME EACH 82955 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $5.00 $5.00 $7.86 65% of Billed Charges 65% of Billed Charges 30516496 LAB/GENERAL RL-ASSAY OF SIROLIMUS EACH 80195 $35.00 301 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.08 $7.08 $11.12 65% of Billed Charges 65% of Billed Charges 30513493 LAB/GENERAL RL-BCR/ABL1 GENE MAJOR BP EACH 81206 $410.00 310 $287.00 $205.00 $328.00 65% of Billed Charges 80% of Billed Charges $80.53 $80.53 $132.81 65% of Billed Charges 65% of Billed Charges 30513501 LAB/GENERAL RL-BCR/ABL1 GENE MINOR BP EACH 81207 $363.00 310 $254.10 $181.50 $290.40 65% of Billed Charges 80% of Billed Charges $71.13 $71.13 $117.32 65% of Billed Charges 65% of Billed Charges 30516140 LAB/GENERAL RL-BETA-2 GLYCOPROT ANTIBODY 1 EACH 86146 $64.00 300 $44.80 $32.00 $51.20 65% 80% 50% Non Payable 65% 65% 65% 30516157 LAB/GENERAL RL-BETA-2 GLYCOPROT ANTIBODY 2 EACH 86146 $64.00 300 $44.80 $32.00 $51.20 65% 80% 50% Non Payable 65% 65% 65% 30516165 LAB/GENERAL RL-BETA-2 GLYCOPROT ANTIBODY 3 EACH 86146 $64.00 300 $44.80 $32.00 $51.20 65% 80% 50% Non Payable 65% 65% 65% 30513857 LAB/GENERAL RL-BRAF EACH 81210 $439.00 310 $307.30 $219.50 $351.20 65% of Billed Charges 80% of Billed Charges $64.53 $64.53 $142.07 65% of Billed Charges 65% of Billed Charges 30501118 LAB/GENERAL RL-CALCITONIN EACH 82308 $67.00 301 $46.90 $33.50 $53.60 65% of Billed Charges 80% of Billed Charges $13.81 $13.81 $21.70 65% of Billed Charges 65% of Billed Charges 30501142 LAB/GENERAL RL-CALCIUM TOTAL EACH 82310 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.66 $2.66 $4.18 65% of Billed Charges 65% of Billed Charges 30501167 LAB/GENERAL RL-CALCULUS ANLYS INFRARED EACH 82365 $33.00 301 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.65 $6.65 $10.45 65% of Billed Charges 65% of Billed Charges 30515696 LAB/GENERAL RL-CARB ANALYSIS SINGLE QUAL EACH 84376 $14.00 305 $9.80 $7.00 $11.20 65% of Billed Charges 80% of Billed Charges $2.84 $2.84 $4.46 65% of Billed Charges 65% of Billed Charges 30501290 LAB/GENERAL RL-CATECHOLAMINES BLOOD EACH 82383 $73.00 301 $51.10 $36.50 $58.40 65% of Billed Charges 80% of Billed Charges $12.92 $12.92 $23.55 65% of Billed Charges 65% of Billed Charges 30501308 LAB/GENERAL RL-CATECHOLAMINES FRACTION UR EACH 82384 $64.00 301 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $13.02 $13.02 $20.45 65% of Billed Charges 65% of Billed Charges 30501316 LAB/GENERAL RL-CATECHOLAMINES TOTAL URINE EACH 82382 $69.00 301 $48.30 $34.50 $55.20 65% of Billed Charges 80% of Billed Charges $8.87 $8.87 $22.11 65% of Billed Charges 65% of Billed Charges 30513907 LAB/GENERAL RL-CEBPA EACH 81218 $605.00 310 $423.50 $302.50 $484.00 65% of Billed Charges 80% of Billed Charges $118.62 $118.62 $195.94 65% of Billed Charges 65% of Billed Charges 30501407 LAB/GENERAL RL-CERULOPLASMIN BLOOD EACH 82390 $27.00 301 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $5.54 $5.54 $8.70 65% of Billed Charges 65% of Billed Charges 30512214 LAB/GENERAL RL-CHEMILUMINESCENT ASSAY EACH 82397 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.29 $7.29 $11.44 65% of Billed Charges 65% of Billed Charges 30501449 LAB/GENERAL RL-CHLAMYDIA ANTIBODY IGM EACH 86632 $32.00 302 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.54 $6.54 $10.27 65% of Billed Charges 65% of Billed Charges 30501746 LAB/GENERAL RL-CHROMATO QL COLUMN EACH 82542 $61.00 301 $42.70 $30.50 $48.80 65% of Billed Charges 80% of Billed Charges $9.31 $9.31 $19.51 65% of Billed Charges 65% of Billed Charges 30501787 LAB/GENERAL RL-CITRATE EACH 82507 $70.00 301 $49.00 $35.00 $56.00 65% of Billed Charges 80% of Billed Charges $14.34 $14.34 $22.52 65% of Billed Charges 65% of Billed Charges 30501852 LAB/GENERAL RL-CMV ANTIBODY IGM EACH 86645 $43.00 302 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.68 $8.68 $13.65 65% of Billed Charges 65% of Billed Charges 30501928 LAB/GENERAL RL-COLD AGGLUTININ TITER EACH 86157 $21.00 302 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $4.16 $4.16 $6.53 65% of Billed Charges 65% of Billed Charges 30501969 LAB/GENERAL RL-COMPLEMENT ANTIGEN EA COMP EACH 86160 $30.00 302 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.19 $6.19 $9.72 65% of Billed Charges 65% of Billed Charges 30502017 LAB/GENERAL RL-COMPLEMENT TOTAL (CH50) EACH 86162 $51.00 302 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.48 $10.48 $16.46 65% of Billed Charges 65% of Billed Charges 30502025 LAB/GENERAL RL-COMPLEX SPEC STAIN O/P TRIC EACH 87209 $45.00 300 $31.50 $22.50 $36.00 65% 80% 50% 50% 65% 65% 65% 30502173 LAB/GENERAL RL-C-PEPTIDE EACH 84681 $53.00 301 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $10.73 $10.73 $16.86 65% of Billed Charges 65% of Billed Charges 30502298 LAB/GENERAL RL-CRYOGLOBULIN QL OR SQN EACH 82595 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.24 65% of Billed Charges 65% of Billed Charges 30502330 LAB/GENERAL RL-CRYPTOCOCCUS ANTIBODY EACH 86641 $37.00 302 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.43 $7.43 $11.67 65% of Billed Charges 65% of Billed Charges 30502686 LAB/GENERAL RL-CULTURE VIRUS ID TISSUE EACH 87252 $66.00 300 $46.20 $33.00 $52.80 65% 80% 50% 50% 65% 65% 65% 30502702 LAB/GENERAL RL-CYCLOSPORINE (SANDIMMUNE) EACH 80158 $46.00 301 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $9.31 $9.31 $14.62 65% of Billed Charges 65% of Billed Charges 30515969 LAB/GENERAL RL-CYP2C19 GENE COM VARIANTS EACH 81225 $729.00 300 $510.30 $364.50 $583.20 65% 80% 50% 50% 65% 65% 65% 30515985 LAB/GENERAL RL-CYP2C9 GENE COM VARIANTS EACH 81227 $438.00 300 $306.60 $219.00 $350.40 65% 80% 50% 50% 65% 65% 65% 30515977 LAB/GENERAL RL-CYP2D6 GENE COM VARIANTS EACH 81226 "$1,128.00 " 300 $789.60 $564.00 $902.40 65% 80% 50% 50% 65% 65% 65% 30515993 LAB/GENERAL RL-CYP3A4 GENE COMMON VARIANTS EACH 81230 $438.00 300 $306.60 $219.00 $350.40 65% 80% 50% 50% 65% 65% 65% 30516009 LAB/GENERAL RL-CYP3A5 GENE COMMON VARIANTS EACH 81231 $438.00 300 $306.60 $219.00 $350.40 65% 80% 50% 50% 65% 65% 65% 30514467 LAB/GENERAL RL-CYSTIC FIBROSIS EXP SCREEN EACH 81220 "$1,392.00 " 310 $974.40 $696.00 "$1,113.60 " 65% of Billed Charges 80% of Billed Charges $200.38 $200.38 $450.85 65% of Billed Charges 65% of Billed Charges 30512271 LAB/GENERAL RL-CYTOGEN M ARRAY COPY NO&SNP EACH 81229 "$2,900.00 " 310 "$2,030.00 " "$1,450.00 " "$2,320.00 " 65% of Billed Charges 80% of Billed Charges $417.60 $417.60 $939.60 65% of Billed Charges 65% of Billed Charges 30502777 LAB/GENERAL RL-DEOXYCORTISOL EACH 82634 $74.00 301 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $15.09 $15.09 $23.72 65% of Billed Charges 65% of Billed Charges 30502801 LAB/GENERAL RL-DESOXYCORTICOSTERONE EACH 82633 $78.00 301 $54.60 $39.00 $62.40 65% of Billed Charges 80% of Billed Charges $15.97 $15.97 $25.09 65% of Billed Charges 65% of Billed Charges 30516736 LAB/GENERAL RL-DGP ANTIBODY EACH IG 1 EACH 86258 $31.00 301 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $4.15 Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 30516744 LAB/GENERAL RL-DGP ANTIBODY EACH IG 2 EACH 86258 $31.00 301 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $4.15 Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 30502843 LAB/GENERAL RL-DHEA-S EACH 82627 $56.00 301 $39.20 $28.00 $44.80 65% of Billed Charges 80% of Billed Charges $11.47 $11.47 $18.01 65% of Billed Charges 65% of Billed Charges 30516553 LAB/GENERAL RL-DIHYDROTESTOSTERON EACH 82642 $74.00 301 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $11.71 $11.71 $23.72 65% of Billed Charges 65% of Billed Charges 30502918 LAB/GENERAL RL-DIHYDROTESTOSTERONE EACH 80327 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $12.65 $12.65 $0.01 65% of Billed Charges 65% of Billed Charges 30502942 LAB/GENERAL RL-DIPTHERIA ANTIBODY EACH 86648 $287.00 302 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $7.84 $7.84 $12.32 65% of Billed Charges 65% of Billed Charges 30502959 LAB/GENERAL RL-DNA DOUBLE STRAND ANTIBODY EACH 86225 $35.00 302 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.08 $7.08 $11.13 65% of Billed Charges 65% of Billed Charges 30513832 LAB/GENERAL RL-DNA PROBE 9TH EACH 88271 $54.00 311 $37.80 $27.00 $43.20 65% of Billed Charges 80% of Billed Charges $11.04 $11.04 $17.35 65% of Billed Charges 65% of Billed Charges 30516017 LAB/GENERAL RL-DPYD GENE COMMON VARIANTS EACH 81232 $438.00 300 $306.60 $219.00 $350.40 65% 80% 50% 50% 65% 65% 65% 30516488 LAB/GENERAL RL-DRUG ASSAY ITRACONAZOLE EACH 80189 $68.00 301 $47.60 $34.00 $54.40 65% of Billed Charges 80% of Billed Charges $9.76 $9.76 Non Payable 65% of Billed Charges 65% of Billed Charges 30516322 LAB/GENERAL RL-DRUG ASSAY VEDOLIZUMAB EACH 80280 $97.00 300 $67.90 $48.50 $77.60 65% 80% 50% 50% 65% 65% 65% 30503098 LAB/GENERAL RL-DRUG SCR SGL PROPOXYPHENE EACH 80367 $68.00 301 $47.60 $34.00 $54.40 65% of Billed Charges 80% of Billed Charges $8.79 $8.79 $0.01 65% of Billed Charges 65% of Billed Charges 30516512 LAB/GENERAL RL-DRUG SCREEN BUPRENORPHINE EACH 80348 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $5.83 $5.83 $0.01 65% of Billed Charges 65% of Billed Charges 30516504 LAB/GENERAL RL-DRUG SCREEN QUANTALCOHOLS EACH 80320 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $8.47 $8.47 $0.01 65% of Billed Charges 65% of Billed Charges 30516470 LAB/GENERAL RL-DRUG SCRN MYCOPHENOLATE EACH 80180 $46.00 301 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $8.87 $8.87 $14.62 65% of Billed Charges 65% of Billed Charges 30503163 LAB/GENERAL RL-EBV VCA ANTIBODY ANTIBODY EACH 86665 $46.00 302 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $9.35 $9.35 $14.69 65% of Billed Charges 65% of Billed Charges 30503320 LAB/GENERAL RL-EIA QL HEPATITIS BE ANTIGEN EACH 87350 $29.00 306 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.94 $5.94 $9.34 65% of Billed Charges 65% of Billed Charges 30503346 LAB/GENERAL RL-EIA QL HISTOPLASMA ANTIGEN EACH 87385 $34.00 306 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $10.73 65% of Billed Charges 65% of Billed Charges 30503353 LAB/GENERAL RL-EIA QL HIV 1 ANTIGEN EACH 87390 $61.00 306 $42.70 $30.50 $48.80 65% of Billed Charges 80% of Billed Charges $9.10 $9.10 $19.49 65% of Billed Charges 65% of Billed Charges 30516561 LAB/GENERAL RL-EL-1 FECAL QUANTITATIVE EACH 82653 $58.00 301 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges $8.27 $8.27 Non Payable 65% of Billed Charges 65% of Billed Charges 30503569 LAB/GENERAL RL-ENCEPHALITIS EAST EQUINE AB EACH 86652 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30503619 LAB/GENERAL RL-ERYTHROPOIETIN EACH 82668 $47.00 301 $32.90 $23.50 $37.60 65% of Billed Charges 80% of Billed Charges $9.69 $9.69 $15.22 65% of Billed Charges 65% of Billed Charges 30503635 LAB/GENERAL RL-ESTRIOL EACH 82677 $61.00 301 $42.70 $30.50 $48.80 65% of Billed Charges 80% of Billed Charges $12.47 $12.47 $19.59 65% of Billed Charges 65% of Billed Charges 30503684 LAB/GENERAL RL-ETHOSUXIMIDE EACH 80168 $41.00 301 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $8.43 $8.43 $13.24 65% of Billed Charges 65% of Billed Charges 30503692 LAB/GENERAL RL-ETHYLENE GLYCOL EACH 82693 $38.00 301 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.68 $7.68 $12.07 65% of Billed Charges 65% of Billed Charges 30516520 LAB/GENERAL RL-F2 GENE EACH 81240 $165.00 301 $115.50 $82.50 $132.00 65% of Billed Charges 80% of Billed Charges $24.17 $24.17 $53.21 65% of Billed Charges 65% of Billed Charges 30516538 LAB/GENERAL RL-F5 GENE EACH 81241 $184.00 301 $128.80 $92.00 $147.20 65% of Billed Charges 80% of Billed Charges $30.01 $30.01 $59.43 65% of Billed Charges 65% of Billed Charges 30503742 LAB/GENERAL RL-FACTOR INHIBITOR VIII EACH 85335 $33.00 305 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.64 $6.64 $10.42 65% of Billed Charges 65% of Billed Charges 30503759 LAB/GENERAL RL-FACTOR IX CHRISTMAS/PTC EACH 85250 $48.00 305 $33.60 $24.00 $38.40 65% of Billed Charges 80% of Billed Charges $9.82 $9.82 $15.42 65% of Billed Charges 65% of Billed Charges 30503767 LAB/GENERAL RL-FACTOR V EACH 85220 $45.00 305 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.10 $9.10 $14.30 65% of Billed Charges 65% of Billed Charges 30503775 LAB/GENERAL RL-FACTOR VII EACH 85230 $45.00 305 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.23 $9.23 $14.50 65% of Billed Charges 65% of Billed Charges 30503783 LAB/GENERAL RL-FACTOR VIII AHG EACH 85240 $45.00 305 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.23 $9.23 $14.50 65% of Billed Charges 65% of Billed Charges 30503817 LAB/GENERAL RL-FACTOR VIII VW MULTIMETRIC EACH 85247 $58.00 305 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges $11.83 $11.83 $18.58 65% of Billed Charges 65% of Billed Charges 30503833 LAB/GENERAL RL-FACTOR X STUART-PROWER EACH 85260 $45.00 305 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.23 $9.23 $14.50 65% of Billed Charges 65% of Billed Charges 30503841 LAB/GENERAL RL-FACTOR XI PTA EACH 85270 $45.00 305 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.23 $9.23 $14.50 65% of Billed Charges 65% of Billed Charges 30503858 LAB/GENERAL RL-FACTOR XII HAGEMAN EACH 85280 $49.00 305 $34.30 $24.50 $39.20 65% of Billed Charges 80% of Billed Charges $9.98 $9.98 $15.67 65% of Billed Charges 65% of Billed Charges 30503874 LAB/GENERAL RL-FACTOR XIII SOLUBILITY SCR EACH 85291 $23.00 305 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $4.59 $4.59 $7.38 65% of Billed Charges 65% of Billed Charges 30503882 LAB/GENERAL RL-FAT DIFFERENTIAL QN FECES EACH 82715 $58.00 301 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges $8.87 $8.87 $18.61 65% of Billed Charges 65% of Billed Charges 30503890 LAB/GENERAL RL-FAT LIPIDS FECES QL EACH 82705 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.62 $2.62 $4.13 65% of Billed Charges 65% of Billed Charges 30512909 LAB/GENERAL RL-FENTANYL EACH 80354 $287.00 301 $200.90 $143.50 $229.60 65% of Billed Charges 80% of Billed Charges $8.79 $8.79 $0.01 65% of Billed Charges 65% of Billed Charges 30512644 LAB/GENERAL RL-FETOMATERNL BLEED FLOW CYTO EACH 86849 $217.00 302 $151.90 $108.50 $173.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 30504047 LAB/GENERAL RL-FLM L/S RATIO EACH 83661 $55.00 301 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges $11.34 $11.34 $17.81 65% of Billed Charges 65% of Billed Charges 30513923 LAB/GENERAL RL-FLT3 (ITD) EACH 81245 $414.00 310 $289.80 $207.00 $331.20 65% of Billed Charges 80% of Billed Charges $59.73 $59.73 $134.06 65% of Billed Charges 65% of Billed Charges 30513931 LAB/GENERAL RL-FLT3 (TKD) EACH 81246 $208.00 310 $145.60 $104.00 $166.40 65% of Billed Charges 80% of Billed Charges $29.88 $29.88 $67.23 65% of Billed Charges 65% of Billed Charges 30504096 LAB/GENERAL RL-FLUORESCENT ANTIBODY SCREEN EACH 86255 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.21 $6.21 $9.76 65% of Billed Charges 65% of Billed Charges 30516645 LAB/GENERAL RL-FMR1 GENE CHARAC ALLELES EACH 81244 $113.00 310 $79.10 $56.50 $90.40 65% of Billed Charges 80% of Billed Charges $16.16 $16.16 $36.36 65% of Billed Charges 65% of Billed Charges 30511539 LAB/GENERAL RL-FMR1 GENE DETECTION EACH 81243 $143.00 310 $100.10 $71.50 $114.40 65% of Billed Charges 80% of Billed Charges $20.53 $20.53 $46.20 65% of Billed Charges 65% of Billed Charges 30516025 LAB/GENERAL RL-G6PD GENE ALYS CMN VARIANT EACH 81247 $438.00 300 $306.60 $219.00 $350.40 65% 80% 50% 50% 65% 65% 65% 30504278 LAB/GENERAL RL-GAMMAGLOBULIN IGE EACH 82785 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.49 $8.49 $13.33 65% of Billed Charges 65% of Billed Charges 30504419 LAB/GENERAL RL-GASTRIN SERUM EACH 82941 $45.00 301 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $9.09 $9.09 $14.28 65% of Billed Charges 65% of Billed Charges 30504450 LAB/GENERAL RL-GLUCAGON EACH 82943 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.37 $7.37 $11.57 65% of Billed Charges 65% of Billed Charges 30512933 LAB/GENERAL RL-GLUCOSE BODY FLUID EACH 82945 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $2.02 $2.02 $3.18 65% of Billed Charges 65% of Billed Charges 30504617 LAB/GENERAL RL-GLYCATED PROTEIN FRUCTOSAM EACH 82985 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $7.77 $7.77 $13.58 65% of Billed Charges 65% of Billed Charges 30504716 LAB/GENERAL RL-HALOPERIDOL (HALDOL) EACH 80173 $40.00 301 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $7.51 $7.51 $12.78 65% of Billed Charges 65% of Billed Charges 30504732 LAB/GENERAL RL-HAPTOGLOBIN QN EACH 83010 $32.00 301 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.49 $6.49 $10.19 65% of Billed Charges 65% of Billed Charges 30516272 LAB/GENERAL RL-HBB FULL GENE SEQUENCE EACH 81364 $812.00 300 $568.40 $406.00 $649.60 65% 80% 50% 50% 65% 65% 65% 30516991 LAB/GENERAL RL-HBB GENE COM VARIANTS EACH 81361 $438.00 311 $306.60 $219.00 $350.40 65% of Billed Charges 80% of Billed Charges $62.93 $62.93 $141.60 65% of Billed Charges 65% of Billed Charges 30505093 LAB/GENERAL RL-HEPATITIS BE AB (HBEAB) EACH 86707 $29.00 302 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.97 $5.97 $9.37 65% of Billed Charges 65% of Billed Charges 30505101 LAB/GENERAL RL-HEPATITIS C AB CONFIRM EACH 86804 $39.00 302 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $7.99 $7.99 $12.55 65% of Billed Charges 65% of Billed Charges 30505127 LAB/GENERAL RL-HEPATITIS DELTA ANTIBODY EACH 86692 $43.00 302 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.85 $8.85 $13.90 65% of Billed Charges 65% of Billed Charges 30505168 LAB/GENERAL RL-HETEROPHILE ANTIBODY SCREEN EACH 86308 $13.00 302 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.67 $2.67 $4.20 65% of Billed Charges 65% of Billed Charges 30512230 LAB/GENERAL RL-HFR GENE ANAL COMMON VARI EACH 81291 $164.00 310 $114.80 $82.00 $131.20 65% of Billed Charges 80% of Billed Charges $21.44 $21.44 $52.93 65% of Billed Charges 65% of Billed Charges 30512651 LAB/GENERAL RL-HIV INTEGRASE SEQUENCE EACH 87906 $322.00 306 $225.40 $161.00 $257.60 65% of Billed Charges 80% of Billed Charges $65.21 $65.21 $104.27 65% of Billed Charges 65% of Billed Charges 30514038 LAB/GENERAL "RL-HLA IDENTIFICATION, CLASS 1" EACH 86832 $810.00 300 $567.00 $405.00 $648.00 65% 80% 50% 50% 65% 65% 65% 30514046 LAB/GENERAL "RL-HLA IDENTIFICATION, CLASS 2" EACH 86833 $815.00 300 $570.50 $407.50 $652.00 65% 80% 50% 50% 65% 65% 65% 30514012 LAB/GENERAL "RL-HLA SCREEN, CLASS 1 " EACH 86830 $239.00 300 $167.30 $119.50 $191.20 65% 80% 50% 50% 65% 65% 65% 30514020 LAB/GENERAL "RL-HLA SCREEN, CLASS 2 " EACH 86831 $205.00 300 $143.50 $102.50 $164.00 65% 80% 50% 50% 65% 65% 65% 30512602 LAB/GENERAL RL-HLA-B DETERMINATION EACH 81381 $425.00 310 $297.50 $212.50 $340.00 65% of Billed Charges 80% of Billed Charges $46.45 $46.45 $137.62 65% of Billed Charges 65% of Billed Charges 30505309 LAB/GENERAL RL-HOMOCYSTINE EACH 83090 $45.00 301 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $8.70 $8.70 $14.52 65% of Billed Charges 65% of Billed Charges 30505358 LAB/GENERAL RL-HTLV OR HIV AB CONFIRM (WB) EACH 86689 $49.00 302 $34.30 $24.50 $39.20 65% of Billed Charges 80% of Billed Charges $9.98 $9.98 $15.67 65% of Billed Charges 65% of Billed Charges 30516546 LAB/GENERAL RL-HTT GENE DETC ABNOR ALLELES EACH 81271 $343.00 301 $240.10 $171.50 $274.40 65% of Billed Charges 80% of Billed Charges $49.32 $49.32 $110.97 65% of Billed Charges 65% of Billed Charges 30505416 LAB/GENERAL RL-HYDROXYPROGESTERONE 17-D EACH 83498 $68.00 301 $47.60 $34.00 $54.40 65% of Billed Charges 80% of Billed Charges $14.01 $14.01 $22.01 65% of Billed Charges 65% of Billed Charges 30516074 LAB/GENERAL RL-IFNL3 GENE EACH 81283 $184.00 300 $128.80 $92.00 $147.20 65% 80% 50% 50% 65% 65% 65% 30516298 LAB/GENERAL RL-IG LIGHT CHAINS FREE EACH 1 EACH 83521 $44.00 300 $30.80 $22.00 $35.20 65% 80% 50% 50% 65% 65% 65% 30516306 LAB/GENERAL RL-IG LIGHT CHAINS FREE EACH 2 EACH 83521 $44.00 300 $30.80 $22.00 $35.20 65% 80% 50% 50% 65% 65% 65% 30514384 LAB/GENERAL RL-IMMUNGLOB HEAVY CHAIN LOCUS EACH 81261 $495.00 310 $346.50 $247.50 $396.00 65% of Billed Charges 80% of Billed Charges $97.24 $97.24 $160.37 65% of Billed Charges 65% of Billed Charges 30505804 LAB/GENERAL RL-IMMUNO QN OTHER EACH 83520 $44.00 301 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $6.67 $6.67 $13.99 65% of Billed Charges 65% of Billed Charges 30505812 LAB/GENERAL RL-IMMUNO QN RIA CHROMOGRANIN EACH 83519 $46.00 301 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $6.97 $6.97 $14.90 65% of Billed Charges 65% of Billed Charges 30505838 LAB/GENERAL RL-IMMUNO TUMR AG CA 15-3 EACH 86300 $53.00 302 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $10.73 $10.73 $16.86 65% of Billed Charges 65% of Billed Charges 30511075 LAB/GENERAL RL-IMMUNOASSAY NONANTIBODY EACH 83516 $29.00 301 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.95 $5.95 $9.34 65% of Billed Charges 65% of Billed Charges 30505960 LAB/GENERAL RL-IMMUNOFIXAT ELECTRO OTHER EACH 86335 $74.00 302 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $15.13 $15.13 $23.77 65% of Billed Charges 65% of Billed Charges 30514392 LAB/GENERAL RL-IMMUNOGLO KAPPA LIGHT CHAIN EACH 81264 $432.00 310 $302.40 $216.00 $345.60 65% of Billed Charges 80% of Billed Charges $73.34 $73.34 $139.91 65% of Billed Charges 65% of Billed Charges 30505986 LAB/GENERAL RL-IMMUNOGLOBULIN SUBCLASSES EACH 82787 $21.00 301 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $4.14 $4.14 $6.50 65% of Billed Charges 65% of Billed Charges 30506034 LAB/GENERAL RL-INHIBIN A EACH 86336 $39.00 302 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $8.04 $8.04 $12.63 65% of Billed Charges 65% of Billed Charges 30506075 LAB/GENERAL RL-INSULIN ANTIBODY EACH 86337 $54.00 302 $37.80 $27.00 $43.20 65% of Billed Charges 80% of Billed Charges $11.04 $11.04 $17.34 65% of Billed Charges 65% of Billed Charges 30506117 LAB/GENERAL RL-INTRINSIC FACTOR ANTIBODY EACH 86340 $38.00 302 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.77 $7.77 $12.21 65% of Billed Charges 65% of Billed Charges 30506158 LAB/GENERAL RL-ISLET CELL ANTIBODY 1 EACH 86341 $59.00 302 $41.30 $29.50 $47.20 65% of Billed Charges 80% of Billed Charges $10.20 $10.20 $19.09 65% of Billed Charges 65% of Billed Charges 30513949 LAB/GENERAL RL-KIT (V-KIT HARDY-ZUCKERMAN) EACH 81272 $824.00 310 $576.80 $412.00 $659.20 65% of Billed Charges 80% of Billed Charges $118.62 $118.62 $266.90 65% of Billed Charges 65% of Billed Charges 30516678 LAB/GENERAL RL-KRAS GENE ADDL VARIANTS EACH 81276 $484.00 301 $338.80 $242.00 $387.20 65% of Billed Charges 80% of Billed Charges $70.99 $70.99 $156.53 65% of Billed Charges 65% of Billed Charges 30516660 LAB/GENERAL RL-KRAS GENE VARIANTS EXON 2 EACH 81275 $484.00 301 $338.80 $242.00 $387.20 65% of Billed Charges 80% of Billed Charges $71.09 $71.09 $156.53 65% of Billed Charges 65% of Billed Charges 30506299 LAB/GENERAL RL-LEAD EACH 83655 $31.00 301 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.24 $6.24 $9.81 65% of Billed Charges 65% of Billed Charges 30506307 LAB/GENERAL RL-LEGIONELLA ANTIBODY EACH 86713 $39.00 302 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $7.89 $7.89 $12.39 65% of Billed Charges 65% of Billed Charges 30506323 LAB/GENERAL RL-LEPTOSPIRA ANTIBODY EACH 86720 $41.00 302 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $13.12 65% of Billed Charges 65% of Billed Charges 30506364 LAB/GENERAL RL-LEUKOCYTE ALK PHOS W/COUNT EACH 85540 $22.00 305 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges $4.44 $4.44 $6.97 65% of Billed Charges 65% of Billed Charges 30517148 LAB/GENERAL RL-LEVETIRACETAM EACH 80177 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.51 $6.51 $10.73 65% of Billed Charges 65% of Billed Charges 30506398 LAB/GENERAL RL-LIDOCAINE EACH 80176 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.57 $7.57 $11.90 65% of Billed Charges 65% of Billed Charges 30506489 LAB/GENERAL RL-LYME DISEASE ANTIBODY EACH 86618 $43.00 302 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.78 $8.78 $13.79 65% of Billed Charges 65% of Billed Charges 30511547 LAB/GENERAL RL-MASS SPECTROMETRY QUANT EACH 83789 $61.00 301 $42.70 $30.50 $48.80 65% of Billed Charges 80% of Billed Charges $9.31 $9.31 $19.53 65% of Billed Charges 65% of Billed Charges 30506695 LAB/GENERAL RL-MEAT FIBERS FECES EACH 89160 $18.00 309 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $1.90 $1.90 $3.93 65% of Billed Charges 65% of Billed Charges 30506737 LAB/GENERAL RL-MERCURY URINE EACH 83825 $41.00 301 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $8.38 $8.38 $13.17 65% of Billed Charges 65% of Billed Charges 30506745 LAB/GENERAL RL-METANEPHRINES BLOOD EACH 83835 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.73 $8.73 $13.72 65% of Billed Charges 65% of Billed Charges 30512222 LAB/GENERAL RL-MICROSATELLITE INSTABILITY EACH 81301 $872.00 310 $610.40 $436.00 $697.60 65% of Billed Charges 80% of Billed Charges $142.21 $142.21 $282.33 65% of Billed Charges 65% of Billed Charges 30517106 LAB/GENERAL RL-MLH1 METHYLATION EACH 81288 $481.00 300 $336.70 $240.50 $384.80 65% 80% 50% 50% 65% 65% 65% 30516033 LAB/GENERAL RL-MOPATH PROCEDURE LEVEL 1 EACH 81400 $160.00 300 $112.00 $80.00 $128.00 65% 80% 50% 50% 65% 65% 65% 30507099 LAB/GENERAL RL-MURAMIDASE EACH 85549 $47.00 305 $32.90 $23.50 $37.60 65% of Billed Charges 80% of Billed Charges $9.67 $9.67 $15.19 65% of Billed Charges 65% of Billed Charges 30516264 LAB/GENERAL RL-MYD88 GENE P.LEU265PRO VRNT EACH 81305 $439.00 300 $307.30 $219.50 $351.20 65% 80% 50% 50% 65% 65% 65% 30511455 LAB/GENERAL RL-NEPHELOMETRY EA ANALYTE NES EACH 83883 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $7.01 $7.01 $11.02 65% of Billed Charges 65% of Billed Charges 30507313 LAB/GENERAL RL-NOCARDIA ANTIBODY EACH 86744 $40.00 302 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $12.95 65% of Billed Charges 65% of Billed Charges 30513915 LAB/GENERAL RL-NPM1 EACH 81310 $617.00 310 $431.90 $308.50 $493.60 65% of Billed Charges 80% of Billed Charges $88.97 $88.97 $199.68 65% of Billed Charges 65% of Billed Charges 30507412 LAB/GENERAL RL-NUCLEIC ACID AMP HEPATITS B EACH 87516 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507537 LAB/GENERAL RL-NUCLEIC ACID AMP PROBE HIV1 EACH 87535 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $18.10 $18.10 $28.42 65% of Billed Charges 65% of Billed Charges 30507552 LAB/GENERAL RL-NUCLEIC ACID AMP PROBE HPV EACH 87624 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $17.19 $17.19 $28.42 65% of Billed Charges 65% of Billed Charges 30507636 LAB/GENERAL RL-NUCLEIC ACID DIRECT CMV EACH 87495 $76.00 306 $53.20 $38.00 $60.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $24.32 65% of Billed Charges 65% of Billed Charges 30507743 LAB/GENERAL RL-NUCLEIC ACID DIRECT INF EACH 87797 $76.00 306 $53.20 $38.00 $60.80 65% of Billed Charges 80% of Billed Charges $10.34 $10.34 $24.32 65% of Billed Charges 65% of Billed Charges 30507933 LAB/GENERAL RL-NUCLEIC ACID QN CMV EACH 87497 $108.00 306 $75.60 $54.00 $86.40 65% of Billed Charges 80% of Billed Charges $22.09 $22.09 $34.70 65% of Billed Charges 65% of Billed Charges 30508188 LAB/GENERAL RL-OLIGOCLONAL BANDS CSF EACH 83916 $69.00 301 $48.30 $34.50 $55.20 65% of Billed Charges 80% of Billed Charges $10.37 $10.37 $22.19 65% of Billed Charges 65% of Billed Charges 30511083 LAB/GENERAL RL-ORGANIC ACID SINGLE QUANT EACH 83921 $54.00 301 $37.80 $27.00 $43.20 65% of Billed Charges 80% of Billed Charges $8.49 $8.49 $17.18 65% of Billed Charges 65% of Billed Charges 30516959 LAB/GENERAL RL-ORTHOPOXVIRUS AMP PRB 1 EACH 87593 $206.00 306 $144.20 $103.00 $164.80 65% of Billed Charges 80% of Billed Charges $18.42 $18.42 Non Payable 65% of Billed Charges 65% of Billed Charges 30516967 LAB/GENERAL RL-ORTHOPOXVIRUS AMP PRB 2 EACH 87593 $206.00 306 $144.20 $103.00 $164.80 65% of Billed Charges 80% of Billed Charges $18.42 $18.42 Non Payable 65% of Billed Charges 65% of Billed Charges 30508261 LAB/GENERAL RL-OSMOTIC FRAG RBC UNINCUB EACH 85555 $19.00 305 $13.30 $9.50 $15.20 65% of Billed Charges 80% of Billed Charges $3.45 $3.45 $6.05 65% of Billed Charges 65% of Billed Charges 30508410 LAB/GENERAL RL-PARVOVIRUS B19 ANTIBODY EACH 86747 $38.00 302 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.75 $7.75 $12.17 65% of Billed Charges 65% of Billed Charges 30515761 LAB/GENERAL RL-PHENOTYPE INFECT AGENT DRUG EACH 87900 $326.00 306 $228.20 $163.00 $260.80 65% of Billed Charges 80% of Billed Charges $67.21 $67.21 $105.58 65% of Billed Charges 65% of Billed Charges 30508550 LAB/GENERAL RL-PHOSPHATIDYLGLYCEROL EACH 84081 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.52 $8.52 $13.38 65% of Billed Charges 65% of Billed Charges 30513956 LAB/GENERAL RL-PML/RARALPHA EACH 81315 $519.00 310 $363.30 $259.50 $415.20 65% of Billed Charges 80% of Billed Charges $101.82 $101.82 $167.92 65% of Billed Charges 65% of Billed Charges 30508691 LAB/GENERAL RL-PORPHOBILINOGEN URINE QL EACH 84106 $15.00 301 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $2.21 $2.21 $4.71 65% of Billed Charges 65% of Billed Charges 30508725 LAB/GENERAL RL-PORPHYRINS URINE QL EACH 84119 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $4.44 $4.44 $10.82 65% of Billed Charges 65% of Billed Charges 30508733 LAB/GENERAL RL-PORPHYRINS URINE QN FRACT EACH 84120 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.59 $7.59 $11.92 65% of Billed Charges 65% of Billed Charges 30513253 LAB/GENERAL RL-PREGNENOLONE EACH 84140 $52.00 301 $36.40 $26.00 $41.60 65% of Billed Charges 80% of Billed Charges $10.66 $10.66 $16.74 65% of Billed Charges 65% of Billed Charges 30508808 LAB/GENERAL RL-PRIMIDONE EACH 80188 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.56 $8.56 $13.44 65% of Billed Charges 65% of Billed Charges 30508816 LAB/GENERAL RL-PROCAINAMIDE EACH 80190 $150.00 301 $105.00 $75.00 $120.00 65% of Billed Charges 80% of Billed Charges $8.64 $8.64 $48.60 65% of Billed Charges 65% of Billed Charges 30515670 LAB/GENERAL RL-PROCALCITONIN EACH 84145 $69.00 301 $48.30 $34.50 $55.20 65% of Billed Charges 80% of Billed Charges $9.99 $9.99 $22.05 65% of Billed Charges 65% of Billed Charges 30508832 LAB/GENERAL RL-PROINSULIN EACH 84206 $67.00 301 $46.90 $33.50 $53.60 65% of Billed Charges 80% of Billed Charges $9.19 $9.19 $21.62 65% of Billed Charges 65% of Billed Charges 30508873 LAB/GENERAL RL-PROSTATE SPECIFIC AG FREE EACH 84154 $46.00 301 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $9.48 $9.48 $14.90 65% of Billed Charges 65% of Billed Charges 30597256 LAB/GENERAL RL-PROTEIN CSF OTHER SOURCE EACH 84157 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $1.89 $1.89 $3.24 65% of Billed Charges 65% of Billed Charges 30508949 LAB/GENERAL RL-PROTEIN S TOTAL EACH 85305 $30.00 305 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $5.98 $5.98 $9.40 65% of Billed Charges 65% of Billed Charges 30509004 LAB/GENERAL RL-PROTEIN WESTERN BLOT BND ID EACH 84182 $74.00 301 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $9.28 $9.28 $23.66 65% of Billed Charges 65% of Billed Charges 30509020 LAB/GENERAL RL-PROTOPORPHYRIN RBC QN EACH 84202 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.40 $7.40 $11.62 65% of Billed Charges 65% of Billed Charges 30509046 LAB/GENERAL RL-PROTOZOA AB NONSPECIFIED EACH 86753 $31.00 302 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $6.39 $6.39 $10.04 65% of Billed Charges 65% of Billed Charges 30509079 LAB/GENERAL RL-PYRUVATE EACH 84210 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $5.60 $5.60 $11.73 65% of Billed Charges 65% of Billed Charges 30513378 LAB/GENERAL RL-QNATAL ADVANCE EACH 81420 "$1,898.00 " 310 "$1,328.60 " $949.00 "$1,518.40 " 65% of Billed Charges 80% of Billed Charges $288.84 $288.84 $614.83 65% of Billed Charges 65% of Billed Charges 30509095 LAB/GENERAL RL-QUINIDINE EACH 80194 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.53 $7.53 $11.83 65% of Billed Charges 65% of Billed Charges 30509129 LAB/GENERAL RL-RAST ALLERGEN IGG QN SQ EA EACH 86001 $20.00 302 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $2.69 $2.69 $6.33 65% of Billed Charges 65% of Billed Charges 30509194 LAB/GENERAL RL-RENIN EACH 84244 $55.00 301 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges $11.34 $11.34 $17.81 65% of Billed Charges 65% of Billed Charges 30509269 LAB/GENERAL RL-RSV ANTIBODY EACH 86756 $40.00 302 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $6.65 $6.65 $12.87 65% of Billed Charges 65% of Billed Charges 30509426 LAB/GENERAL RL-SEROTONIN BLOOD EACH 84260 $78.00 301 $54.60 $39.00 $62.40 65% of Billed Charges 80% of Billed Charges $15.97 $15.97 $25.09 65% of Billed Charges 65% of Billed Charges 30509434 LAB/GENERAL RL-SEX HORMONE BINDING GLOB EACH 84270 $55.00 301 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges $11.21 $11.21 $17.60 65% of Billed Charges 65% of Billed Charges 30516082 LAB/GENERAL RL-SLCO1B1 GENE COM VARIANTS EACH 81328 $438.00 300 $306.60 $219.00 $350.40 65% 80% 50% 50% 65% 65% 65% 30514475 LAB/GENERAL RL-SMA CARRIER SCREEN EACH 81329 $343.00 310 $240.10 $171.50 $274.40 65% of Billed Charges 80% of Billed Charges $49.32 $49.32 $110.97 65% of Billed Charges 65% of Billed Charges 30509566 LAB/GENERAL RL-SMEAR OVA PARASITE CNCNT/ID EACH 87177 $23.00 300 $16.10 $11.50 $18.40 65% 80% 50% 50% 65% 65% 65% 30512289 LAB/GENERAL "RL-SNRPN/UBE3A GENE EG, PRADER" EACH 81331 $128.00 310 $89.60 $64.00 $102.40 65% of Billed Charges 80% of Billed Charges $18.39 $18.39 $41.37 65% of Billed Charges 65% of Billed Charges 30509632 LAB/GENERAL RL-SOMATOMEDIN EACH 84305 $54.00 301 $37.80 $27.00 $43.20 65% of Billed Charges 80% of Billed Charges $10.96 $10.96 $17.22 65% of Billed Charges 65% of Billed Charges 30509921 LAB/GENERAL RL-SYPHILIS VDRL RPR QL EACH 86592 $11.00 302 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $2.20 $2.20 $3.46 65% of Billed Charges 65% of Billed Charges 30509954 LAB/GENERAL RL-T CELLS CD4 COUNT EACH 86361 $67.00 302 $46.90 $33.50 $53.60 65% of Billed Charges 80% of Billed Charges $13.81 $13.81 $21.69 65% of Billed Charges 65% of Billed Charges 30509970 LAB/GENERAL RL-TACROLIMUS (FK-506) EACH 80197 $35.00 301 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.08 $7.08 $11.12 65% of Billed Charges 65% of Billed Charges 30509988 LAB/GENERAL RL-TB TEST CELL IMM MEAS IN AG EACH 86480 $155.00 302 $108.50 $77.50 $124.00 65% of Billed Charges 80% of Billed Charges $31.96 $31.96 $50.20 65% of Billed Charges 65% of Billed Charges 30510028 LAB/GENERAL RL-TETANUS ANTIBODY EACH 86774 $37.00 302 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.63 $7.63 $11.99 65% of Billed Charges 65% of Billed Charges 30510051 LAB/GENERAL RL-THERAPEUTIC DRUG OTHER EACH 80299 $47.00 301 $32.90 $23.50 $37.60 65% of Billed Charges 80% of Billed Charges $7.06 $7.06 $15.10 65% of Billed Charges 65% of Billed Charges 30510069 LAB/GENERAL RL-THIOCYANATE EACH 84430 $30.00 301 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.00 $6.00 $9.42 65% of Billed Charges 65% of Billed Charges 30516579 LAB/GENERAL RL-THIOPURIN S-MTHYLTRNSFRS EACH 86051 $29.00 301 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $4.15 Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 30510077 LAB/GENERAL RL-THROMBIN TIME PLASMA EACH 85670 $15.00 305 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $2.98 $2.98 $4.67 65% of Billed Charges 65% of Billed Charges 30510150 LAB/GENERAL RL-THYROID STIMULATING IM GLOB EACH 84445 $128.00 301 $89.60 $64.00 $102.40 65% of Billed Charges 80% of Billed Charges $26.22 $26.22 $41.20 65% of Billed Charges 65% of Billed Charges 30510317 LAB/GENERAL RL-TOXOPLASMA AB IGM EACH 86778 $37.00 302 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.43 $7.43 $11.67 65% of Billed Charges 65% of Billed Charges 30516090 LAB/GENERAL RL-TPMT GENE COM VARIANTS EACH 81335 $438.00 300 $306.60 $219.00 $350.40 65% 80% 50% 50% 65% 65% 65% 30513980 LAB/GENERAL RL-TRB EACH 81340 $523.00 310 $366.10 $261.50 $418.40 65% of Billed Charges 80% of Billed Charges $102.61 $102.61 $169.23 65% of Billed Charges 65% of Billed Charges 30513964 LAB/GENERAL RL-TRG EACH 81342 $504.00 310 $352.80 $252.00 $403.20 65% of Billed Charges 80% of Billed Charges $98.96 $98.96 $163.22 65% of Billed Charges 65% of Billed Charges 30516108 LAB/GENERAL RL-UGT1A1 GENE COMMON VARIANTS EACH 81350 $585.00 300 $409.50 $292.50 $468.00 65% 80% 50% 50% 65% 65% 65% 30510655 LAB/GENERAL RL-URINE VOLUME MEASURE EACH 81050 $10.00 307 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $1.54 $1.54 $2.95 65% of Billed Charges 65% of Billed Charges 30510713 LAB/GENERAL RL-VANILLYLMAND ACID(VMA) UR EACH 84585 $39.00 301 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $8.00 $8.00 $12.56 65% of Billed Charges 65% of Billed Charges 30510721 LAB/GENERAL RL-VARICELLA ZOSTER ANTIBODY EACH 86787 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.65 $6.65 $10.43 65% of Billed Charges 65% of Billed Charges 30510747 LAB/GENERAL RL-VASOPRESSIN (ADH) EACH 84588 $85.00 301 $59.50 $42.50 $68.00 65% of Billed Charges 80% of Billed Charges $17.50 $17.50 $27.49 65% of Billed Charges 65% of Billed Charges 30510770 LAB/GENERAL RL-VIRUS NOT ELSEWHERE SPEC EACH 86790 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.65 $6.65 $10.43 65% of Billed Charges 65% of Billed Charges 30510788 LAB/GENERAL RL-VISCOSITY BLOOD EACH 85810 $30.00 305 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $9.45 65% of Billed Charges 65% of Billed Charges 30516116 LAB/GENERAL RL-VKORC1 GENE EACH 81355 $221.00 300 $154.70 $110.50 $176.80 65% 80% 50% 50% 65% 65% 65% 30510937 LAB/GENERAL RL-VOLATILES METHANOL EACH 84600 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.29 $8.29 $13.86 65% of Billed Charges 65% of Billed Charges 30510960 LAB/GENERAL RL-XYLOSE ABSORPTION EACH 84620 $33.00 301 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.11 $6.11 $10.46 65% of Billed Charges 65% of Billed Charges 30509251 LAB/GENERAL ROTAVIRUS ANTIBODY EACH 86759 $46.00 302 $32.20 $23.00 $36.80 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $14.77 65% of Billed Charges 65% of Billed Charges 30509277 LAB/GENERAL RUBELLA ANTIBODY EACH 86762 $36.00 302 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.42 $7.42 $11.66 65% of Billed Charges 65% of Billed Charges 30513196 LAB/GENERAL RUBEOLA ANTIBODY EACH 86765 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.65 $6.65 $10.43 65% of Billed Charges 65% of Billed Charges 30515605 LAB/GENERAL RUSSELL VIPER VENOM DILUTED EACH 85613 $24.00 305 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $4.93 $4.93 $7.76 65% of Billed Charges 65% of Billed Charges 30509293 LAB/GENERAL RUSSELL VIPER VENOM UNDILUTED EACH 85612 $44.00 305 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $4.93 $4.93 $14.17 65% of Billed Charges 65% of Billed Charges 30509335 LAB/GENERAL SALMONELLA ANTIBODY EACH 86768 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30509343 LAB/GENERAL SED RATE RBC NON AUTO EACH 85651 $11.00 305 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $1.83 $1.83 $3.46 65% of Billed Charges 65% of Billed Charges 30511570 LAB/GENERAL "SEDIMENTATION RATE, AUTOMATED " EACH 85652 $7.00 300 $4.90 $3.50 $5.60 65% 80% 50% Non Payable 65% 65% 65% 30509350 LAB/GENERAL SELENIUM EACH 84255 $64.00 301 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $13.16 $13.16 $20.68 65% of Billed Charges 65% of Billed Charges 30509368 LAB/GENERAL SEMEN ANALYSIS KRUGER EACH 89322 $67.00 309 $46.90 $33.50 $53.60 65% of Billed Charges 80% of Billed Charges $7.99 $7.99 $12.56 65% of Billed Charges 65% of Billed Charges 30509376 LAB/GENERAL SEMEN ANLYS CMPL EACH 89320 $50.00 309 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $6.21 $6.21 $9.97 65% of Billed Charges 65% of Billed Charges 30509384 LAB/GENERAL SEMEN ANLYS CMPL EACH 89320 $50.00 309 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $6.21 $6.21 $9.97 65% of Billed Charges 65% of Billed Charges 30509392 LAB/GENERAL SEMEN MOTILITY/CNT W/O HUHN EACH 89310 $29.00 309 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $4.44 $4.44 $6.97 65% of Billed Charges 65% of Billed Charges 30509400 LAB/GENERAL SEMEN PRES/MOTILITY W/HUHN EACH 89300 $44.00 309 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $4.60 $4.60 $7.97 65% of Billed Charges 65% of Billed Charges 30509418 LAB/GENERAL SEMEN PRESENCE/MOTILITY EACH 89321 $50.00 309 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $6.21 $6.21 $9.76 65% of Billed Charges 65% of Billed Charges 30509442 LAB/GENERAL SHIGELLA ANTIBODY EACH 86771 $62.00 302 $43.40 $31.00 $49.60 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $19.83 65% of Billed Charges 65% of Billed Charges 30509459 LAB/GENERAL SIALIC ACID EACH 84275 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.93 $6.93 $10.89 65% of Billed Charges 65% of Billed Charges 30509467 LAB/GENERAL SICKLE CELL RBC EACH 85660 $14.00 305 $9.80 $7.00 $11.20 65% of Billed Charges 80% of Billed Charges $2.84 $2.84 $4.46 65% of Billed Charges 65% of Billed Charges 30509475 LAB/GENERAL SILICA EACH 84285 $64.00 301 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $12.14 $12.14 $20.42 65% of Billed Charges 65% of Billed Charges 30509483 LAB/GENERAL SKIN TEST CANDIDA EACH 86485 $74.00 302 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $1.94 $1.94 $17.31 65% of Billed Charges 65% of Billed Charges 30509491 LAB/GENERAL SKIN TEST COCCIDIOIDOMYCOSIS EACH 86490 $152.00 302 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $1.94 $1.94 $75.58 65% of Billed Charges 65% of Billed Charges 30509509 LAB/GENERAL SKIN TEST HISTOPLASMOSIS EACH 86510 $100.00 302 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges $1.94 $1.94 $6.02 65% of Billed Charges 65% of Billed Charges 30509517 LAB/GENERAL SKIN TEST TB INTRADERMAL EACH 86580 $74.00 302 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $1.94 $1.94 $8.15 65% of Billed Charges 65% of Billed Charges 30509525 LAB/GENERAL SKIN TEST UNLISTED ANTIGEN EACH 86486 $74.00 302 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $1.94 $1.94 $4.81 65% of Billed Charges 65% of Billed Charges 30509533 LAB/GENERAL SMEAR ACID FAST/FLUORESCENT EACH 87206 $14.00 300 $9.80 $7.00 $11.20 65% 80% 50% 50% 65% 65% 65% 30509541 LAB/GENERAL SMEAR GRAM/GIEMSA EACH 87205 $11.00 300 $7.70 $5.50 $8.80 65% 80% 50% 50% 65% 65% 65% 30509558 LAB/GENERAL SMEAR NASAL EOSINOPHILS EACH 89190 $23.00 309 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $2.45 $2.45 $4.69 65% of Billed Charges 65% of Billed Charges 30509582 LAB/GENERAL SMEAR WET MOUNT SALINE/INK EACH 87210 $15.00 300 $10.50 $7.50 $12.00 65% 80% 50% 50% 65% 65% 65% 30509590 LAB/GENERAL SODIUM BLOOD EACH 84295 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.48 $2.48 $3.90 65% of Billed Charges 65% of Billed Charges 30509608 LAB/GENERAL SODIUM OTHER EACH 84302 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.51 $2.51 $3.94 65% of Billed Charges 65% of Billed Charges 30509624 LAB/GENERAL SODIUM URINE EACH 84300 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.51 $2.51 $4.10 65% of Billed Charges 65% of Billed Charges 30509640 LAB/GENERAL SPECIAL STAIN INCLS BODS/PARS EACH 87207 $15.00 300 $10.50 $7.50 $12.00 65% 80% 50% 50% 65% 65% 65% 30509657 LAB/GENERAL SPECIFIC GRAVITY BODY FLUID EACH 84315 $9.00 301 $6.30 $4.50 $7.20 65% of Billed Charges 80% of Billed Charges $1.29 $1.29 $2.66 65% of Billed Charges 65% of Billed Charges 30509665 LAB/GENERAL SPECTROPHOTOMETRY EACH 84311 $21.00 301 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges $3.60 $3.60 $6.56 65% of Billed Charges 65% of Billed Charges 30509681 LAB/GENERAL SPERM ANTIBODY EACH 89325 $53.00 309 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges $5.50 $5.50 $8.64 65% of Billed Charges 65% of Billed Charges 30509699 LAB/GENERAL SPERM EVAL CERVICAL MUCUS PEN EACH 89330 $49.00 309 $34.30 $24.50 $39.20 65% of Billed Charges 80% of Billed Charges $5.10 $5.10 $8.41 65% of Billed Charges 65% of Billed Charges 30509707 LAB/GENERAL SPERM EVAL HAMSTER PEN EACH 89329 $103.00 309 $72.10 $51.50 $82.40 65% of Billed Charges 80% of Billed Charges $10.81 $10.81 $15.87 65% of Billed Charges 65% of Billed Charges 30509715 LAB/GENERAL SPERM ID ASPIRATION NONSEMINAL EACH 89257 $134.00 309 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $350.54 65% of Billed Charges 65% of Billed Charges 30509723 LAB/GENERAL SPERM ID TESTIS TISSUE EACH 89264 $134.00 309 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $344.85 65% of Billed Charges 65% of Billed Charges 30509731 LAB/GENERAL SPERM ISOLATION CPLX PREP EACH 89261 $134.00 309 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $85.92 65% of Billed Charges 65% of Billed Charges 30509749 LAB/GENERAL SPERM ISOLATION SMP PREP EACH 89260 $134.00 309 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $97.95 65% of Billed Charges 65% of Billed Charges 30509756 LAB/GENERAL SPUTUM COLLECTION EACH 89220 $423.00 309 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $14.22 65% of Billed Charges 65% of Billed Charges 30509764 LAB/GENERAL STAIN FAT FECES URINE SPUTUM EACH 89125 $14.00 309 $9.80 $7.00 $11.20 65% of Billed Charges 80% of Billed Charges $2.23 $2.23 $4.76 65% of Billed Charges 65% of Billed Charges 30509780 LAB/GENERAL STEM CELLS TOTAL EACH 86367 $195.00 302 $136.50 $97.50 $156.00 65% of Billed Charges 80% of Billed Charges $19.45 $19.45 $63.00 65% of Billed Charges 65% of Billed Charges 30515373 LAB/GENERAL STREP PNEUM?ANTIGENS URINE EACH 87899 $41.00 306 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $13.02 65% of Billed Charges 65% of Billed Charges 30509798 LAB/GENERAL STREPTOKINASE ANTIBODY EACH 86590 $32.00 302 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $5.69 $5.69 $10.25 65% of Billed Charges 65% of Billed Charges 30509806 LAB/GENERAL STREPTOZYME SCREEN EACH 86063 $15.00 302 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $2.98 $2.98 $4.67 65% of Billed Charges 65% of Billed Charges 30509814 LAB/GENERAL SUGARS CHROMATOGRAPHY EACH 84375 $98.00 301 $68.60 $49.00 $78.40 65% of Billed Charges 80% of Billed Charges $10.11 $10.11 $31.59 65% of Billed Charges 65% of Billed Charges 30509822 LAB/GENERAL SULFHEMOGLOBIN QL EACH 83060 $22.00 301 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges $4.27 $4.27 $7.13 65% of Billed Charges 65% of Billed Charges 30509848 LAB/GENERAL SUSCEPT AFB TB EACH 87190 $19.00 300 $13.30 $9.50 $15.20 65% 80% 50% 50% 65% 65% 65% 30509855 LAB/GENERAL SUSCEPT AGAR EACH 87181 $12.00 300 $8.40 $6.00 $9.60 65% 80% 50% 50% 65% 65% 65% 30509863 LAB/GENERAL SUSCEPT DISK KIRBY BAUER EACH 87184 $19.00 300 $13.30 $9.50 $15.20 65% 80% 50% 50% 65% 65% 65% 30509871 LAB/GENERAL SUSCEPT ENZYME DETEC EACH 87185 $12.00 300 $8.40 $6.00 $9.60 65% 80% 50% 50% 65% 65% 65% 30509889 LAB/GENERAL SUSCEPT MACROTUBE EACH 87188 $17.00 300 $11.90 $8.50 $13.60 65% 80% 50% 50% 65% 65% 65% 30509897 LAB/GENERAL SUSCEPT MIC EACH 87186 $22.00 300 $15.40 $11.00 $17.60 65% 80% 50% 50% 65% 65% 65% 30509905 LAB/GENERAL SUSCEPT MLC EACH 87187 $101.00 300 $70.70 $50.50 $80.80 65% 80% 50% 50% 65% 65% 65% 30509913 LAB/GENERAL SWEAT COLLECTION IONTOPHORESIS EACH 89230 $134.00 309 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $2.38 65% of Billed Charges 65% of Billed Charges 30509939 LAB/GENERAL SYPHILIS VDRL RPR QN EACH 86593 $11.00 302 $7.70 $5.50 $8.80 65% of Billed Charges 80% of Billed Charges $2.27 $2.27 $3.56 65% of Billed Charges 65% of Billed Charges 30509947 LAB/GENERAL T CELLS CD4 CD8 RATIO EACH 86360 $118.00 302 $82.60 $59.00 $94.40 65% of Billed Charges 80% of Billed Charges $24.23 $24.23 $38.05 65% of Billed Charges 65% of Billed Charges 30509962 LAB/GENERAL T CELLS TOTAL EACH 86359 $95.00 302 $66.50 $47.50 $76.00 65% of Billed Charges 80% of Billed Charges $19.45 $19.45 $30.56 65% of Billed Charges 65% of Billed Charges 30509996 LAB/GENERAL TEICHOIC ACID ANTIBODY EACH 86609 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.65 $6.65 $10.43 65% of Billed Charges 65% of Billed Charges 30510002 LAB/GENERAL TESTOSTERONE FREE EACH 84402 $64.00 301 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $13.13 $13.13 $20.63 65% of Billed Charges 65% of Billed Charges 30513204 LAB/GENERAL TESTOSTERONE TOTAL EACH 84403 $65.00 301 $45.50 $32.50 $52.00 65% of Billed Charges 80% of Billed Charges $13.31 $13.31 $20.91 65% of Billed Charges 65% of Billed Charges 30510036 LAB/GENERAL THAWING & EXPANSION FROZEN CEL EACH 88241 $31.00 311 $21.70 $15.50 $24.80 65% of Billed Charges 80% of Billed Charges $5.21 $5.21 $9.79 65% of Billed Charges 65% of Billed Charges 30510044 LAB/GENERAL THEOPHYLLINE EACH 80198 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.30 $7.30 $11.45 65% of Billed Charges 65% of Billed Charges 30510085 LAB/GENERAL THROMBIN TIME TITER EACH 85675 $18.00 305 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.53 $3.53 $5.55 65% of Billed Charges 65% of Billed Charges 30510093 LAB/GENERAL THROMBOPLASTIN INHIBITION EACH 85705 $25.00 305 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $4.96 $4.96 $7.80 65% of Billed Charges 65% of Billed Charges 30510101 LAB/GENERAL THYROGLOBULIN EACH 84432 $41.00 301 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $8.28 $8.28 $13.01 65% of Billed Charges 65% of Billed Charges 30510119 LAB/GENERAL THYROGLOBULIN ANTIBODY EACH 86800 $40.00 302 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges $8.20 $8.20 $12.89 65% of Billed Charges 65% of Billed Charges 30510127 LAB/GENERAL THYROID ACTIVITY (TBG) EACH 84442 $37.00 301 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $7.63 $7.63 $11.97 65% of Billed Charges 65% of Billed Charges 30510135 LAB/GENERAL THYROID HORMONE UPTAKE RATIO EACH 84479 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.24 65% of Billed Charges 65% of Billed Charges 30510143 LAB/GENERAL THYROID STIMULATING HORMONE EACH 84443 $42.00 301 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $8.66 $8.66 $13.61 65% of Billed Charges 65% of Billed Charges 30510168 LAB/GENERAL THYROXINE (T-4) ELUTION EACH 84437 $17.00 301 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $3.34 $3.34 $5.24 65% of Billed Charges 65% of Billed Charges 30513212 LAB/GENERAL THYROXINE (T-4) FREE EACH 84439 $23.00 301 $16.10 $11.50 $18.40 65% of Billed Charges 80% of Billed Charges $4.65 $4.65 $7.31 65% of Billed Charges 65% of Billed Charges 30510184 LAB/GENERAL THYROXINE (T-4) TOTAL EACH 84436 $18.00 301 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.54 $3.54 $5.56 65% of Billed Charges 65% of Billed Charges 30510192 LAB/GENERAL TISS CULT SKIN/OTHR SOLID TISS EACH 88233 $352.00 311 $246.40 $176.00 $281.60 65% of Billed Charges 80% of Billed Charges $72.57 $72.57 $113.99 65% of Billed Charges 65% of Billed Charges 30510200 LAB/GENERAL TISSUE CULT AMNIOTIC/CHORIONIC EACH 88235 $376.00 311 $263.20 $188.00 $300.80 65% of Billed Charges 80% of Billed Charges $75.93 $75.93 $121.74 65% of Billed Charges 65% of Billed Charges 30510218 LAB/GENERAL TISSUE CULT BONE MARROW EACH 88237 $360.00 311 $252.00 $180.00 $288.00 65% of Billed Charges 80% of Billed Charges $65.13 $65.13 $116.44 65% of Billed Charges 65% of Billed Charges 30510226 LAB/GENERAL TISSUE CULT NONNEO LYMPH EACH 88230 $292.00 311 $204.40 $146.00 $233.60 65% of Billed Charges 80% of Billed Charges $60.07 $60.07 $94.36 65% of Billed Charges 65% of Billed Charges 30510234 LAB/GENERAL TISSUE CULT TUMR EACH 88239 $369.00 311 $258.30 $184.50 $295.20 65% of Billed Charges 80% of Billed Charges $76.07 $76.07 $119.49 65% of Billed Charges 65% of Billed Charges 30510259 LAB/GENERAL TISSUE EXAM FUNGUS EACH 87220 $11.00 300 $7.70 $5.50 $8.80 65% 80% 50% 50% 65% 65% 65% 30510267 LAB/GENERAL TOBRAMYCIN PEAK EACH 80200 $41.00 301 $28.70 $20.50 $32.80 65% of Billed Charges 80% of Billed Charges $8.31 $8.31 $13.07 65% of Billed Charges 65% of Billed Charges 30510291 LAB/GENERAL TOPIRAMATE EACH 80201 $30.00 301 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $6.15 $6.15 $9.66 65% of Billed Charges 65% of Billed Charges 30510309 LAB/GENERAL TOXIN ANTITOXIN ASSAY EACH 87230 $50.00 300 $35.00 $25.00 $40.00 65% 80% 50% 50% 65% 65% 65% 30510325 LAB/GENERAL TOXOPLASMA AB SCR EACH 86777 $36.00 302 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.42 $7.42 $11.66 65% of Billed Charges 65% of Billed Charges 30510341 LAB/GENERAL TRANSFERRIN EACH 84466 $32.00 301 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.58 $6.58 $10.34 65% of Billed Charges 65% of Billed Charges 30510358 LAB/GENERAL TRANSFUSION REACTION EACH 86078 $423.00 305 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $44.78 65% of Billed Charges 65% of Billed Charges 30510366 LAB/GENERAL TRH STIMULATION PANEL 1 HR EACH 80438 $127.00 301 $88.90 $63.50 $101.60 65% of Billed Charges 80% of Billed Charges $25.98 $25.98 $40.83 65% of Billed Charges 65% of Billed Charges 30510374 LAB/GENERAL TRH STIMULATION PANEL 2 HR EACH 80439 $169.00 301 $118.30 $84.50 $135.20 65% of Billed Charges 80% of Billed Charges $34.65 $34.65 $54.44 65% of Billed Charges 65% of Billed Charges 30510382 LAB/GENERAL TRICHINELLA ANTIBODY EACH 86784 $32.00 302 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $6.48 $6.48 $10.17 65% of Billed Charges 65% of Billed Charges 30510390 LAB/GENERAL TRICHOMNAS VAG ASSAY W/OPTIC EACH 87808 $39.00 306 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $6.18 $6.18 $12.38 65% of Billed Charges 65% of Billed Charges 30512917 LAB/GENERAL TRICHOMONAS EACH 87661 $88.00 306 $61.60 $44.00 $70.40 65% of Billed Charges 80% of Billed Charges $17.23 $17.23 $28.42 65% of Billed Charges 65% of Billed Charges 30510408 LAB/GENERAL TRIGLYCERIDES EACH 84478 $15.00 301 $10.50 $7.50 $12.00 65% of Billed Charges 80% of Billed Charges $2.97 $2.97 $4.65 65% of Billed Charges 65% of Billed Charges 30513220 LAB/GENERAL TRIIODOTHYRONINE (T-3) FREE EACH 84481 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.73 $8.73 $13.72 65% of Billed Charges 65% of Billed Charges 30510424 LAB/GENERAL TRIIODOTHYRONINE (T-3) TOTAL EACH 84480 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.31 $7.31 $11.49 65% of Billed Charges 65% of Billed Charges 30510432 LAB/GENERAL TROPONIN QN EACH 84484 $32.00 301 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges $5.08 $5.08 $10.10 65% of Billed Charges 65% of Billed Charges 30510440 LAB/GENERAL TRYPSIN DUODENAL FLUID EACH 84485 $18.00 301 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.87 $3.87 $5.83 65% of Billed Charges 65% of Billed Charges 30510457 LAB/GENERAL TRYPSIN FECES QL EACH 84488 $19.00 301 $13.30 $9.50 $15.20 65% of Billed Charges 80% of Billed Charges $3.77 $3.77 $5.91 65% of Billed Charges 65% of Billed Charges 30510465 LAB/GENERAL TRYPSIN FECES QN 24 HR EACH 84490 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $3.92 $3.92 $8.04 65% of Billed Charges 65% of Billed Charges 30510473 LAB/GENERAL TYROSINE EACH 84510 $27.00 301 $18.90 $13.50 $21.60 65% of Billed Charges 80% of Billed Charges $5.36 $5.36 $8.61 65% of Billed Charges 65% of Billed Charges 30510481 LAB/GENERAL UREA NITROGEN CLEARANCE EACH 84545 $18.00 301 $12.60 $9.00 $14.40 65% of Billed Charges 80% of Billed Charges $3.41 $3.41 $5.83 65% of Billed Charges 65% of Billed Charges 30510499 LAB/GENERAL UREA NITROGEN QUANTITATIVE EACH 84520 $10.00 301 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges $2.03 $2.03 $3.20 65% of Billed Charges 65% of Billed Charges 30510507 LAB/GENERAL UREA NITROGEN SQ EACH 84525 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $1.94 $1.94 $4.16 65% of Billed Charges 65% of Billed Charges 30510515 LAB/GENERAL UREA NITROGEN URINE EACH 84540 $14.00 301 $9.80 $7.00 $11.20 65% of Billed Charges 80% of Billed Charges $2.45 $2.45 $4.50 65% of Billed Charges 65% of Billed Charges 30510523 LAB/GENERAL URIC ACID BLOOD EACH 84550 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $2.33 $2.33 $3.66 65% of Billed Charges 65% of Billed Charges 30510531 LAB/GENERAL URIC ACID BODY FLUID EACH 84560 $13.00 301 $9.10 $6.50 $10.40 65% of Billed Charges 80% of Billed Charges $2.45 $2.45 $4.11 65% of Billed Charges 65% of Billed Charges 30510564 LAB/GENERAL URINALYSIS AUTO W/MICRO EACH 81001 $8.00 307 $5.60 $4.00 $6.40 65% of Billed Charges 80% of Billed Charges $1.63 $1.63 $2.57 65% of Billed Charges 65% of Billed Charges 30510572 LAB/GENERAL URINALYSIS AUTO W/O MICRO EACH 81003 $6.00 307 $4.20 $3.00 $4.80 65% of Billed Charges 80% of Billed Charges $1.16 $1.16 $1.82 65% of Billed Charges 65% of Billed Charges 30510580 LAB/GENERAL URINALYSIS BACTERIAL SCREEN EACH 81007 $75.00 307 $52.50 $37.50 $60.00 65% of Billed Charges 80% of Billed Charges $1.32 $1.32 $24.28 65% of Billed Charges 65% of Billed Charges 30510598 LAB/GENERAL URINALYSIS MICRO ONLY EACH 81015 $8.00 307 $5.60 $4.00 $6.40 65% of Billed Charges 80% of Billed Charges $1.57 $1.57 $2.47 65% of Billed Charges 65% of Billed Charges 30510606 LAB/GENERAL URINALYSIS NONAUTO ACETONE EACH 81002 $9.00 307 $6.30 $4.50 $7.20 65% of Billed Charges 80% of Billed Charges $1.32 $1.32 $2.82 65% of Billed Charges 65% of Billed Charges 30510622 LAB/GENERAL URINALYSIS QL SQ EACH 81005 $6.00 307 $4.20 $3.00 $4.80 65% of Billed Charges 80% of Billed Charges $1.12 $1.12 $1.76 65% of Billed Charges 65% of Billed Charges 30510630 LAB/GENERAL URINALYSIS UNLSTD PROC EACH 81099 $16.00 307 $11.20 $8.00 $12.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 30510648 LAB/GENERAL URINE PREGNANCY VISUAL EACH 81025 $22.00 307 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges $3.26 $3.26 $6.97 65% of Billed Charges 65% of Billed Charges 30510663 LAB/GENERAL UROBILINOGEN URINE QL EACH 84578 $12.00 301 $8.40 $6.00 $9.60 65% of Billed Charges 80% of Billed Charges $1.67 $1.67 $3.62 65% of Billed Charges 65% of Billed Charges 30510671 LAB/GENERAL UROBILINOGEN URINE QN EACH 84580 $24.00 301 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $3.66 $3.66 $7.74 65% of Billed Charges 65% of Billed Charges 30510689 LAB/GENERAL VANCOMYCIN PEAK EACH 80202 $34.00 301 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $6.98 $6.98 $10.97 65% of Billed Charges 65% of Billed Charges 30510739 LAB/GENERAL VASOACTIVE INTESTINAL PEPTIDE EACH 84586 $89.00 301 $62.30 $44.50 $71.20 65% of Billed Charges 80% of Billed Charges $18.22 $18.22 $28.62 65% of Billed Charges 65% of Billed Charges 30511000 LAB/GENERAL VENIPUNCTURE EACH 36415 $22.00 300 $15.40 $11.00 $17.60 65% 80% 50% 50% 65% 65% 65% 30510754 LAB/GENERAL VIRUS ISOLATE ID EACH 87255 $85.00 300 $59.50 $42.50 $68.00 65% 80% 50% 50% 65% 65% 65% 30510762 LAB/GENERAL VIRUS ISOLATE SHELL ID EACH 87254 $49.00 300 $34.30 $24.50 $39.20 65% 80% 50% 50% 65% 65% 65% 30510796 LAB/GENERAL VIT B1 (THIAMINE) EACH 84425 $54.00 301 $37.80 $27.00 $43.20 65% of Billed Charges 80% of Billed Charges $10.95 $10.95 $17.20 65% of Billed Charges 65% of Billed Charges 30510804 LAB/GENERAL VITAMIN A SERUM EACH 84590 $30.00 301 $21.00 $15.00 $24.00 65% of Billed Charges 80% of Billed Charges $5.98 $5.98 $9.40 65% of Billed Charges 65% of Billed Charges 30510812 LAB/GENERAL VITAMIN B-12 EACH 82607 $38.00 301 $26.60 $19.00 $30.40 65% of Billed Charges 80% of Billed Charges $7.77 $7.77 $12.21 65% of Billed Charges 65% of Billed Charges 30510820 LAB/GENERAL VITAMIN B-12 BINDING CAPACITY EACH 82608 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.38 $7.38 $11.60 65% of Billed Charges 65% of Billed Charges 30510838 LAB/GENERAL VITAMIN B-2 (RIBOFLAVIN) EACH 84252 $51.00 301 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.44 $10.44 $16.39 65% of Billed Charges 65% of Billed Charges 30510846 LAB/GENERAL VITAMIN B-6 (PYRIDOXAL PHOS) EACH 84207 $71.00 301 $49.70 $35.50 $56.80 65% of Billed Charges 80% of Billed Charges $14.49 $14.49 $22.76 65% of Billed Charges 65% of Billed Charges 30510853 LAB/GENERAL VITAMIN C (ASCORBIC ACID) EACH 82180 $25.00 301 $17.50 $12.50 $20.00 65% of Billed Charges 80% of Billed Charges $5.10 $5.10 $8.01 65% of Billed Charges 65% of Billed Charges 30510861 LAB/GENERAL VITAMIN D (1 25 DIHYDROXY) EACH 82652 $97.00 301 $67.90 $48.50 $77.60 65% of Billed Charges 80% of Billed Charges $19.85 $19.85 $31.19 65% of Billed Charges 65% of Billed Charges 30510887 LAB/GENERAL VITAMIN D-3 25-OH EACH 82306 $74.00 301 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $15.26 $15.26 $23.98 65% of Billed Charges 65% of Billed Charges 30510895 LAB/GENERAL VITAMIN E EACH 84446 $36.00 301 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.31 $7.31 $11.49 65% of Billed Charges 65% of Billed Charges 30510903 LAB/GENERAL VITAMIN K EACH 84597 $35.00 301 $24.50 $17.50 $28.00 65% of Billed Charges 80% of Billed Charges $7.07 $7.07 $11.11 65% of Billed Charges 65% of Billed Charges 30510911 LAB/GENERAL VITAMIN OTHER EACH 84591 $43.00 301 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $5.98 $5.98 $13.82 65% of Billed Charges 65% of Billed Charges 30515407 LAB/GENERAL VORICONAZOLE EACH 80285 $68.00 301 $47.60 $34.00 $54.40 65% of Billed Charges 80% of Billed Charges $9.76 $9.76 $21.96 65% of Billed Charges 65% of Billed Charges 30510945 LAB/GENERAL WEST NILE VIRUS ANTIBODY EACH 86789 $36.00 302 $25.20 $18.00 $28.80 65% of Billed Charges 80% of Billed Charges $7.42 $7.42 $11.66 65% of Billed Charges 65% of Billed Charges 30510952 LAB/GENERAL WEST NILE VIRUS ANTIBODY IGM EACH 86788 $43.00 302 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges $8.68 $8.68 $13.65 65% of Billed Charges 65% of Billed Charges 30509574 LAB/GENERAL WET MOUNTS/ W PREPARATIONS EACH Q0111 $17.00 310 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $2.20 $2.20 $12.25 65% of Billed Charges 65% of Billed Charges 30510978 LAB/GENERAL YERSINIA ANTIBODY EACH 86793 $33.00 302 $23.10 $16.50 $26.40 65% of Billed Charges 80% of Billed Charges $6.80 $6.80 $10.68 65% of Billed Charges 65% of Billed Charges 30510994 LAB/GENERAL ZINC URINE EACH 84630 $29.00 301 $20.30 $14.50 $23.20 65% of Billed Charges 80% of Billed Charges $5.87 $5.87 $9.23 65% of Billed Charges 65% of Billed Charges 31000011 LAB/PATH AUTOPSY FORENSIC EXAM EACH 88040 $234.00 310 $163.80 $117.00 $187.20 65% of Billed Charges 80% of Billed Charges $177.32 $177.32 $484.44 65% of Billed Charges 65% of Billed Charges 31000029 LAB/PATH AUTOPSY G & M INFANT EACH 88028 "$1,872.00 " 310 "$1,310.40 " $936.00 "$1,497.60 " 65% of Billed Charges 80% of Billed Charges $63.78 $63.78 $174.34 65% of Billed Charges 65% of Billed Charges 31000037 LAB/PATH AUTOPSY G & M STILLBORN EACH 88029 "$1,872.00 " 310 "$1,310.40 " $936.00 "$1,497.60 " 65% of Billed Charges 80% of Billed Charges $63.78 $63.78 $174.34 65% of Billed Charges 65% of Billed Charges 31000060 LAB/PATH AUTOPSY G & M W/O CNS EACH 88020 $538.00 310 $376.60 $269.00 $430.40 65% of Billed Charges 80% of Billed Charges $109.90 $109.90 $300.39 65% of Billed Charges 65% of Billed Charges 31000078 LAB/PATH AUTOPSY GROSS INFANT EACH 88012 "$1,248.00 " 310 $873.60 $624.00 $998.40 65% of Billed Charges 80% of Billed Charges $63.78 $63.78 $174.34 65% of Billed Charges 65% of Billed Charges 31000086 LAB/PATH AUTOPSY GROSS STILLBORN/NWBRN EACH 88014 "$1,248.00 " 310 $873.60 $624.00 $998.40 65% of Billed Charges 80% of Billed Charges $63.78 $63.78 $159.76 65% of Billed Charges 65% of Billed Charges 31000094 LAB/PATH AUTOPSY GROSS STLLBRN MACERAT EACH 88016 "$1,248.00 " 310 $873.60 $624.00 $998.40 65% of Billed Charges 80% of Billed Charges $81.58 $81.58 $222.94 65% of Billed Charges 65% of Billed Charges 31000110 LAB/PATH AUTOPSY GROSS W/BRAIN & SPINAL EACH 88007 $936.00 310 $655.20 $468.00 $748.80 65% of Billed Charges 80% of Billed Charges $88.73 $88.73 $213.22 65% of Billed Charges 65% of Billed Charges 31000151 LAB/PATH AUTOPSY UNLSTD PROC EACH 88099 "$2,340.00 " 310 "$1,638.00 " "$1,170.00 " "$1,872.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable 65% of Billed Charges 65% of Billed Charges 31000169 LAB/PATH CONSULT PATH REFERRED SLIDE EACH 88321 $100.00 310 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $74.94 65% of Billed Charges 65% of Billed Charges 31000177 LAB/PATH CONSULT PATH REQUIRING PREP EACH 88323 $134.00 310 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $98.16 65% of Billed Charges 65% of Billed Charges 31000185 LAB/PATH CONSULT PATH REVIEW & REPORT EACH 88325 $423.00 310 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $127.47 65% of Billed Charges 65% of Billed Charges 31000193 LAB/PATH CONSULT PATH SURGERY EACH 88329 $152.00 310 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $32.56 65% of Billed Charges 65% of Billed Charges 31000201 LAB/PATH CONSULT PATH SURGERY CYTO INIT EACH 88333 "$2,127.00 " 310 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $77.15 65% of Billed Charges 65% of Billed Charges 31000219 LAB/PATH CONSULT PATH SURGERY EA ADD EACH 88332 $56.00 310 $39.20 $28.00 $44.80 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $46.76 65% of Billed Charges 65% of Billed Charges 31000227 LAB/PATH CONSULT PATH SURGERY EA ADDL EACH 88334 $56.00 310 $39.20 $28.00 $44.80 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $48.21 65% of Billed Charges 65% of Billed Charges 31000235 LAB/PATH CONSULT PATH SURGERY W/FROZEN EACH 88331 $423.00 310 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $84.15 65% of Billed Charges 65% of Billed Charges 31000243 LAB/PATH CYTOPATH CELLULAR ENHANCE TECH EACH 88112 $134.00 311 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $57.72 65% of Billed Charges 65% of Billed Charges 31000250 LAB/PATH CYTOPATH CONCENTRATION EACH 88108 $100.00 311 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $53.27 65% of Billed Charges 65% of Billed Charges 31000276 LAB/PATH CYTOPATH FLD SIMPLE FILTER EACH 88106 $74.00 311 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $55.76 65% of Billed Charges 65% of Billed Charges 31000284 LAB/PATH CYTOPATH FLD SMEAR EACH 88104 $100.00 311 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $58.63 65% of Billed Charges 65% of Billed Charges 31000342 LAB/PATH CYTOPATH FORENSIC EACH 88125 $134.00 311 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $23.05 65% of Billed Charges 65% of Billed Charges 31000359 LAB/PATH CYTOPATH PAP SLIDES MAN S/R EACH 88153 $61.00 311 $42.70 $30.50 $48.80 65% of Billed Charges 80% of Billed Charges $5.45 $5.45 $19.46 65% of Billed Charges 65% of Billed Charges 31000367 LAB/PATH CYTOPATH PAP SLIDES MAN SCRN EACH 88150 $44.00 311 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $5.45 $5.45 $12.25 65% of Billed Charges 65% of Billed Charges 31000375 LAB/PATH CYTOPATH PAP SLIDES MAN/COMP EACH 88152 $70.00 311 $49.00 $35.00 $56.00 65% of Billed Charges 80% of Billed Charges $5.45 $5.45 $22.39 65% of Billed Charges 65% of Billed Charges 31000391 LAB/PATH CYTOPATH PAP SLIDES W/HORM EACH 88155 $37.00 311 $25.90 $18.50 $29.60 65% of Billed Charges 80% of Billed Charges $3.09 $3.09 $11.87 65% of Billed Charges 65% of Billed Charges 31000409 LAB/PATH CYTOPATH PAP SMEAR EACH 88141 $36.51 311 $25.56 $18.26 $29.21 65% of Billed Charges 80% of Billed Charges $11.48 $11.48 $22.20 65% of Billed Charges 65% of Billed Charges 31000417 LAB/PATH CYTOPATH PAP SMEAR AUTO EACH 88147 $127.00 311 $88.90 $63.50 $101.60 65% of Billed Charges 80% of Billed Charges $5.87 $5.87 $40.95 65% of Billed Charges 65% of Billed Charges 31000425 LAB/PATH CYTOPATH PAP SMEAR AUTO/MAN EACH 88148 $44.00 311 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $7.84 $7.84 $12.96 65% of Billed Charges 65% of Billed Charges 31000433 LAB/PATH CYTOPATH PAP TBS MAN S/R EACH 88165 $106.00 311 $74.20 $53.00 $84.80 65% of Billed Charges 80% of Billed Charges $5.45 $5.45 $34.20 65% of Billed Charges 65% of Billed Charges 31000441 LAB/PATH CYTOPATH PAP TBS MAN SCRN EACH 88164 $44.00 311 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $5.45 $5.45 $12.25 65% of Billed Charges 65% of Billed Charges 31000458 LAB/PATH CYTOPATH PAP TBS MAN/COMP EACH 88166 $44.00 311 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $5.45 $5.45 $12.25 65% of Billed Charges 65% of Billed Charges 31000466 LAB/PATH CYTOPATH PAP TBS MAN/COMP CELL EACH 88167 $44.00 311 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $5.45 $5.45 $12.25 65% of Billed Charges 65% of Billed Charges 31000474 LAB/PATH CYTOPATH PAP TLP AUTO SCRN EACH 88174 $64.00 311 $44.80 $32.00 $51.20 65% of Billed Charges 80% of Billed Charges $11.02 $11.02 $20.55 65% of Billed Charges 65% of Billed Charges 31000482 LAB/PATH CYTOPATH PAP TLP AUTO/MAN EACH 88175 $67.00 311 $46.90 $33.50 $53.60 65% of Billed Charges 80% of Billed Charges $13.66 $13.66 $21.55 65% of Billed Charges 65% of Billed Charges 31000490 LAB/PATH CYTOPATH PAP TLP MAN EACH 88142 $51.00 311 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $10.45 $10.45 $16.41 65% of Billed Charges 65% of Billed Charges 31000508 LAB/PATH CYTOPATH PAP TLP MAN S/R EACH 88143 $58.00 311 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges $10.45 $10.45 $18.66 65% of Billed Charges 65% of Billed Charges 31000524 LAB/PATH CYTOPATH SMEAR OTHER 5+ SLIDES EACH 88162 $134.00 311 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $85.13 65% of Billed Charges 65% of Billed Charges 31000532 LAB/PATH CYTOPATH SMEAR OTHER SOURCE EACH 88160 $74.00 311 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $61.11 65% of Billed Charges 65% of Billed Charges 31000540 LAB/PATH CYTOPATH SMEAR OTHER W/PREP EACH 88161 $74.00 311 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $58.68 65% of Billed Charges 65% of Billed Charges 31000557 LAB/PATH CYTOPATH UNLSTD PROC EACH 88199 $134.00 311 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $3.75 $3.75 Non Payable 65% of Billed Charges 65% of Billed Charges 31000565 LAB/PATH DECALCIFICATION EACH 88311 $34.00 310 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $3.75 $3.75 $18.82 65% of Billed Charges 65% of Billed Charges 31000573 LAB/PATH ELECTRON MICROSCOPY DIAGNOSTIC EACH 88348 "$2,127.00 " 310 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% of Billed Charges 80% of Billed Charges $59.33 $59.33 $332.35 65% of Billed Charges 65% of Billed Charges 31000599 LAB/PATH FINE NEEDLE EVAL EACH 88172 $423.00 311 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $47.89 65% of Billed Charges 65% of Billed Charges 31000607 LAB/PATH FINE NEEDLE INTERPRETATION EACH 88173 $134.00 311 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $132.46 65% of Billed Charges 65% of Billed Charges 31000615 LAB/PATH FLOW CYTOM CELL CYCLE/DNA EACH 88182 $134.00 311 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $118.48 65% of Billed Charges 65% of Billed Charges 31000623 LAB/PATH FLOW CYTOMETRY 1ST MARKER TC EACH 88184 $889.00 311 $622.30 $444.50 $711.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $57.91 65% of Billed Charges 65% of Billed Charges 31000631 LAB/PATH FLOW CYTOMETRY EA ADD MRKR TC EACH 88185 $56.00 311 $39.20 $28.00 $44.80 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $18.83 65% of Billed Charges 65% of Billed Charges 31000649 LAB/PATH FLOW CYTOMETRY INTERP 16+ MRK EACH 88189 $117.00 311 $81.90 $58.50 $93.60 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $75.49 65% of Billed Charges 65% of Billed Charges 31000656 LAB/PATH FLOW CYTOMETRY INTERP 2-8 MRKR EACH 88187 $34.00 311 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $3.75 $3.75 $33.71 65% of Billed Charges 65% of Billed Charges 31000664 LAB/PATH FLOW CYTOMETRY INTERP 9-15 MRK EACH 88188 $117.00 311 $81.90 $58.50 $93.60 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $56.04 65% of Billed Charges 65% of Billed Charges 31000672 LAB/PATH GROSS & MICRO LEVEL II EACH 88302 $74.00 310 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $26.81 65% of Billed Charges 65% of Billed Charges 31000680 LAB/PATH GROSS & MICRO LEVEL III EACH 88304 $134.00 310 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $35.54 65% of Billed Charges 65% of Billed Charges 31000698 LAB/PATH GROSS & MICRO LEVEL IV EACH 88305 $134.00 310 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $59.98 65% of Billed Charges 65% of Billed Charges 31000706 LAB/PATH GROSS & MICRO LEVEL V EACH 88307 $889.00 310 $622.30 $444.50 $711.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $237.02 65% of Billed Charges 65% of Billed Charges 31000714 LAB/PATH GROSS & MICRO LEVEL VI EACH 88309 "$2,127.00 " 310 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $359.47 65% of Billed Charges 65% of Billed Charges 31000722 LAB/PATH GROSS ONLY LEVEL I EACH 88300 $74.00 310 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $13.80 65% of Billed Charges 65% of Billed Charges 31000763 LAB/PATH IF DIRECT AB EA EACH 88346 $423.00 312 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $107.98 65% of Billed Charges 65% of Billed Charges 31000771 LAB/PATH IF INDIRECT AB EA EACH 88350 $407.00 312 $284.90 $203.50 $325.60 65% of Billed Charges 80% of Billed Charges $15.74 $15.74 $79.26 65% of Billed Charges 65% of Billed Charges 31000797 LAB/PATH IMMUNOHISOCHEMISTR EA ANTIBODY EACH 88342 $423.00 310 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $90.10 65% of Billed Charges 65% of Billed Charges 31000813 LAB/PATH IN SITU HYBRIDIZATION (FISH) EACH 88365 $423.00 310 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $155.13 65% of Billed Charges 65% of Billed Charges 31000839 LAB/PATH MICRODISSECTION MANUAL EACH 88381 $229.65 312 $160.76 $114.83 $183.72 65% of Billed Charges 80% of Billed Charges $38.04 $38.04 $154.53 65% of Billed Charges 65% of Billed Charges 31000870 LAB/PATH MORPHO ANLYS COMPUTER ASST EACH 88361 $889.00 310 $622.30 $444.50 $711.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $108.40 65% of Billed Charges 65% of Billed Charges 31000888 LAB/PATH MORPHO ANLYS INSITU HYBRID EACH 88367 $889.00 312 $622.30 $444.50 $711.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $96.75 65% of Billed Charges 65% of Billed Charges 31000904 LAB/PATH MORPHO ANLYS NERVE EACH 88356 $134.00 310 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $202.34 65% of Billed Charges 65% of Billed Charges 31000912 LAB/PATH MORPHO ANLYS SKELETAL MUSCLE EACH 88355 $423.00 310 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $116.73 65% of Billed Charges 65% of Billed Charges 31000920 LAB/PATH MORPHO ANLYS TUMR EACH 88358 $423.00 310 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $114.43 65% of Billed Charges 65% of Billed Charges 31000946 LAB/PATH NERVE TEASING PREPARATIONS EACH 88362 "$2,127.00 " 310 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $195.71 65% of Billed Charges 65% of Billed Charges 31000953 LAB/PATH PATHOLOGY SURGICAL UNLSTD PROC EACH 88399 $134.00 310 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $3.75 $3.75 Non Payable 65% of Billed Charges 65% of Billed Charges 31000961 LAB/PATH PATHOLOGY UNLSTD PROC EACH 89240 $134.00 310 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $3.75 $3.75 Non Payable 65% of Billed Charges 65% of Billed Charges 31000987 LAB/PATH PROTEIN ANLYS W/BAND PROBE EACH 88372 $112.00 312 $78.40 $56.00 $89.60 65% of Billed Charges 80% of Billed Charges $11.73 $11.73 $21.24 65% of Billed Charges 65% of Billed Charges 31000995 LAB/PATH PROTEIN ANLYS WESTERN BLOT EACH 88371 $107.00 312 $74.90 $53.50 $85.60 65% of Billed Charges 80% of Billed Charges $11.46 $11.46 $18.01 65% of Billed Charges 65% of Billed Charges 31000938 LAB/PATH RL-MORPHO ANLYS TUMR MANUAL EACH 88360 $423.00 310 $296.10 $211.50 $338.40 65% of Billed Charges 80% of Billed Charges $12.86 $12.86 $106.97 65% of Billed Charges 65% of Billed Charges 31000896 LAB/PATH RL-MORPHO INSITU HYBRID MAN EACH 88368 $889.00 312 $622.30 $444.50 $711.20 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $112.66 65% of Billed Charges 65% of Billed Charges 31000516 LAB/PATH SCREENING CYTOPATH PAP MAN S/R EACH G0143 $81.00 311 $56.70 $40.50 $64.80 65% of Billed Charges 80% of Billed Charges $10.45 $10.45 $21.91 65% of Billed Charges 65% of Billed Charges 31001001 LAB/PATH SEX CHROMATIN ID BARR BODIES EACH 88130 $45.00 311 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $7.76 $7.76 $14.56 65% of Billed Charges 65% of Billed Charges 31001019 LAB/PATH SEX CHROMATIN ID BLOOD SMEAR EACH 88140 $20.00 311 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges $4.12 $4.12 $6.47 65% of Billed Charges 65% of Billed Charges 31001027 LAB/PATH SPECIAL HISTOCHEM STAIN W/FROZ EACH 88314 $56.00 310 $39.20 $28.00 $44.80 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $83.02 65% of Billed Charges 65% of Billed Charges 31001043 LAB/PATH SPECIAL STAIN GROUP 1 EACH 88312 $134.00 310 $93.80 $67.00 $107.20 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $90.24 65% of Billed Charges 65% of Billed Charges 31000748 LAB/PATH SPECIAL STAIN GROUP III EACH 88319 "$2,127.00 " 310 "$1,488.90 " "$1,063.50 " "$1,701.60 " 65% of Billed Charges 80% of Billed Charges $19.48 $19.48 $95.71 65% of Billed Charges 65% of Billed Charges 31001050 LAB/PATH SPECIAL STAINS GROUP 2 (W/S&I) EACH 88313 $152.00 310 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $6.02 $6.02 $65.29 65% of Billed Charges 65% of Billed Charges 76200013 OBSERVATION INITIAL OBSERVATION CARE EACH G0379 "$1,422.00 " 762 $995.40 $711.00 "$1,137.60 " 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $2001/case $1815/case $1650/case 60% billed charges NTE $2575 " 60% discount NTE $2,100" $500 each paid in addition to other neg. rates 76210012 OBSERVATION OBSERVATION - JSH PER HOUR G0378 $127.00 762 $88.90 $63.50 $101.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $2001/case $1815/case $1650/case 60% billed charges NTE $2575 " 60% discount NTE $2,100" $500 each paid in addition to other neg. rates 76230010 OBSERVATION OBSERVATION - PHCC PER HOUR G0378 $127.00 762 $88.90 $63.50 $101.60 65% Covered Charges NTE $1896/case 80% Covered Charges NTE $2001/case $1815/case $1650/case 60% billed charges NTE $2575 " 60% discount NTE $2,100" $500 each paid in addition to other neg. rates 51200236 ORAL SURGERY ALVEOLOPLASTY W/O EXTRACT 1-3 EACH D7321 $293.00 512 $205.10 $146.50 $234.40 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51200327 ORAL SURGERY ANES ANALGESIA ANXIOLYSIS NITR EACH D9230 $49.00 512 $34.30 $24.50 $39.20 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51200392 ORAL SURGERY ANES NON-INTRAVENOUS CONCIOUS EACH D9248 $200.00 512 $140.00 $100.00 $160.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51200640 ORAL SURGERY BITEWING SINGLE FILM EACH D0270 $225.00 512 $157.50 $112.50 $180.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51200699 ORAL SURGERY BRUSH BIOPSY EACH D7288 $150.00 512 $105.00 $75.00 $120.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51200723 ORAL SURGERY CASE PRESENTATION TX PLAN EACH D9450 $110.00 512 $77.00 $55.00 $88.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51200764 ORAL SURGERY CLOSURE FISTULA OROLANTRAL EACH D7260 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51200780 ORAL SURGERY CLOSURE PERFORATION SINUS PRIM EACH D7261 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51200814 ORAL SURGERY CONSULTATION BY NON-TX PROVIDR EACH D9310 $75.00 512 $52.50 $37.50 $60.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201119 ORAL SURGERY DEBR FULL MOUTH COMPRH EACH D4355 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201127 ORAL SURGERY DELIVERY LOCAL ANTIMICROBIAL EACH D4381 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201135 ORAL SURGERY DENTOALVEOLAR UNLSTD PROC EACH 41899 $604.00 512 $422.80 $302.00 $483.20 Non Payable 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 51201440 ORAL SURGERY EA ADD PREFAB POST SM TOOTH EACH D2957 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201457 ORAL SURGERY ENDODONTIC UNLSTD PROC EACH D3999 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201473 ORAL SURGERY EVALUATION ORAL CMPRH NEW/EST EACH D0150 $327.00 512 $228.90 $163.50 $261.60 Non Payable Not Payable Non Payable Not Payable Non Payable Non Payable Non Payable 51201622 ORAL SURGERY EXTRACTION CORONAL REMNANTS EACH D7111 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201630 ORAL SURGERY EXTRACTION ERUPTED TOOTH/EXPOS EACH D7140 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201671 ORAL SURGERY FIBREOTOMY TRANSSEPTAL SUPRA EACH D7291 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201820 ORAL SURGERY GRAFT CONNECTIVE TISSUE SUBEPI EACH D4273 "$3,771.00 " 512 "$2,639.70 " "$1,885.50 " "$3,016.80 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201846 ORAL SURGERY GRAFT REPLACEMENT BONE EA ADD EACH D4264 "$4,470.00 " 512 "$3,129.00 " "$2,235.00 " "$3,576.00 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201853 ORAL SURGERY GRAFT REPLACEMENT BONE FIRST EACH D4263 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201879 ORAL SURGERY GRAFT SOFT TISSUE PROCEDURE PE EACH D4270 "$3,771.00 " 512 "$2,639.70 " "$1,885.50 " "$3,016.80 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201911 ORAL SURGERY I&D ABSC EXTRA CPLX EACH D7521 "$1,740.00 " 512 "$1,218.00 " $870.00 "$1,392.00 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51201937 ORAL SURGERY I&D ABSC INTRA CPLX EACH D7511 "$1,740.00 " 512 "$1,218.00 " $870.00 "$1,392.00 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51202273 ORAL SURGERY INS IMPL SOFT PALATE MIN 3 IMP EACH C9727 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51202307 ORAL SURGERY LABIAL VENEER RESIN CHAIRSIDE EACH D2960 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51202448 ORAL SURGERY OCCLUSAL ADJUSTMENT CMPL EACH D9952 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51202455 ORAL SURGERY OCCLUSAL ADJUSTMENT LIMITED EACH D9951 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51202463 ORAL SURGERY OCCLUSAL ANLYS MOUNTED CASE EACH D9950 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51205532 ORAL SURGERY "OMFS-BIOPSY, FLOOR OF MOUTH " EACH 41108 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205441 ORAL SURGERY "OMFS-BIOPSY, VESTIBULE MOUTH " EACH 40808 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205409 ORAL SURGERY OMFS-BRISEMENT EACH 21299 $604.00 510 $422.80 $302.00 $483.20 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205326 ORAL SURGERY OMFS-BX BONE DEEP EACH 20245 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205318 ORAL SURGERY OMFS-BX BONE SUPERFICIAL EACH 20240 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205359 ORAL SURGERY "OMFS-EXC BONE MANDIBLE, SEQ " EACH 21025 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205557 ORAL SURGERY OMFS-EXC BONY TUBEROSITIES EACH 41823 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205383 ORAL SURGERY OMFS-EXCISION PALATAL TORI EACH 21032 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205334 ORAL SURGERY OMFS-FB REMOVAL SUPERFICIAL EACH 20670 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205458 ORAL SURGERY OMFS-LABIAL FRENECTOMY EACH 40819 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205540 ORAL SURGERY OMFS-LINGUAL FRENECTOMY EACH 41115 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205516 ORAL SURGERY OMFS-TONGUE BX ANTERIOR 2/3 EACH 41100 "$1,361.00 " 510 $952.70 $680.50 "$1,088.80 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205524 ORAL SURGERY OMFS-TONGUE BX POSTERIOR 1/3 EACH 41105 "$7,961.00 " 510 "$5,572.70 " "$3,980.50 " "$6,368.80 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205466 ORAL SURGERY OMFS-VESTIBULOPLASTY ANTERIOR EACH 40840 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205508 ORAL SURGERY OMFS-VESTIBULOPLASTY COMPLEX EACH 40845 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205490 ORAL SURGERY OMFS-VESTIBULOPLASTY ENTIRE EACH 40844 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205482 ORAL SURGERY OMFS-VESTIBULOPLASTY POST BI EACH 40843 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51205474 ORAL SURGERY OMFS-VESTIBULOPLASTY POST UNI EACH 40842 "$14,480.00 " 510 "$10,136.00 " "$7,240.00 " "$11,584.00 " 65% 80% 50% 50% 65% Non Payable $500 each paid in addition to other neg. rates 51202760 ORAL SURGERY OSSEOUS SURGERY 4 OR > TEETH P EACH D4260 "$14,480.00 " 512 "$10,136.00 " "$7,240.00 " "$11,584.00 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51202786 ORAL SURGERY OSTEOPLASTY ORTHOGNATHIC DEFOR EACH D7940 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51202828 ORAL SURGERY OSTEOTOMY SEGMENTED/SUBAPICAL EACH D7944 "$5,475.00 " 512 "$3,832.50 " "$2,737.50 " "$4,380.00 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51202844 ORAL SURGERY PALLATIVE TX (EMERGENCY) PAIN- EACH D9110 $97.00 512 $67.90 $48.50 $77.60 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51202869 ORAL SURGERY PIN RETENTION PER TOOTH W/RTR EACH D2951 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51202950 ORAL SURGERY PROPHYLAXIS ADULT EACH D1110 $327.00 512 $228.90 $163.50 $261.60 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51205227 ORAL SURGERY RADIATION SHIELD EACH D5984 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51203123 ORAL SURGERY RECEMENT FIXED PARTIAL DENTURE EACH D6930 $128.00 512 $89.60 $64.00 $102.40 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51203453 ORAL SURGERY REMOVAL TOOTH ERUPTING W/FLAP EACH D7210 "$3,771.00 " 512 "$2,639.70 " "$1,885.50 " "$3,016.80 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51203461 ORAL SURGERY REMOVAL TOOTH IMPACTED CMPL EACH D7240 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51203479 ORAL SURGERY REMOVAL TOOTH IMPACTED CMPL W/ EACH D7241 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51203487 ORAL SURGERY REMOVAL TOOTH IMPACTED PART EACH D7230 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51203495 ORAL SURGERY REMOVAL TOOTH IMPACTED SOFT EACH D7220 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51203503 ORAL SURGERY REMOVAL TOOTH ROOT RESIDUAL EACH D7250 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51203867 ORAL SURGERY RESTORATIVE UNLSTD BY REPORT EACH D2999 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51203909 ORAL SURGERY REVISE SURGICAL PROC PER TOOTH EACH D4268 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204022 ORAL SURGERY SPACE MAINTAINER FIXED UNILAT EACH D1510 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204048 ORAL SURGERY SPACE MAINTAINER REMOVE UNILAT EACH D1520 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204113 ORAL SURGERY TEST DIAGNOSTIC CASTS EACH D0470 $85.00 512 $59.50 $42.50 $68.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204139 ORAL SURGERY TEST PULP VITALITY EACH D0460 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204220 ORAL SURGERY TRANSPLANT TOOTH EACH D7272 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204238 ORAL SURGERY TST ACCESSION TISS GRS/MCR SUR EACH D0474 $152.00 512 $106.40 $76.00 $121.60 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204261 ORAL SURGERY TST COLLECTION OF MICROORGANIS EACH D0415 $70.00 512 $49.00 $35.00 $56.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204279 ORAL SURGERY TST CONSULT SLD PREP ELSEWHERE EACH D0484 $194.00 512 $135.80 $97.00 $155.20 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204287 ORAL SURGERY TST CONSULT SLIDE REFER SOURCE EACH D0485 $230.00 512 $161.00 $115.00 $184.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204295 ORAL SURGERY TST CYTOLOGIC SMEARS PREP W/RP EACH D0480 $202.00 512 $141.40 $101.00 $161.60 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204303 ORAL SURGERY TST DECALCIFICATION PROCEDURE EACH D0475 $175.00 512 $122.50 $87.50 $140.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204311 ORAL SURGERY TST DIAG DETECT MUCOS ABNORMAL EACH D0431 $85.00 512 $59.50 $42.50 $68.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204329 ORAL SURGERY TST DIAGNOSTIC ELECTRON MICRO EACH D0481 $284.00 512 $198.80 $142.00 $227.20 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204337 ORAL SURGERY TST DIRECT IMMUNOFLUORESCENC EACH D0482 $126.00 512 $88.20 $63.00 $100.80 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204352 ORAL SURGERY TST INDIRECT IMMUNOFLUORESCENC EACH D0483 $140.00 512 $98.00 $70.00 $112.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204360 ORAL SURGERY TST OTHER PATHOLOGY PROCEDURE EACH D0502 $204.00 512 $142.80 $102.00 $163.20 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204378 ORAL SURGERY TST SPECIAL STAINS MICROORGAN EACH D0476 $300.00 512 $210.00 $150.00 $240.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204386 ORAL SURGERY TST SPECIAL STAINS NON-MICROOR EACH D0477 $300.00 512 $210.00 $150.00 $240.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204394 ORAL SURGERY TST TISS IN SITU HYBRD W/INTER EACH D0479 $260.00 512 $182.00 $130.00 $208.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204428 ORAL SURGERY TX COMPLICATIONS POST SURGICAL EACH D9930 "$2,177.00 " 512 "$1,523.90 " "$1,088.50 " "$1,741.60 " Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204949 ORAL SURGERY XR BITEWINGS 2 FILMS EACH D0272 $225.00 512 $157.50 $112.50 $180.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204964 ORAL SURGERY XR BITEWINGS 4 FILMS EACH D0274 $606.00 512 $424.20 $303.00 $484.80 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51204980 ORAL SURGERY XR EXTRAORAL FILM 1ST EACH D0250 $225.00 512 $157.50 $112.50 $180.00 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable 51205052 ORAL SURGERY XR INTRAORAL FILM OCCLUSAL EACH D0240 $225.00 512 $157.50 $112.50 $180.00 Non Payable Not Payable Non Payable Not Payable Non Payable Non Payable Non Payable 51205110 ORAL SURGERY XR VERTICAL BTWNG 7-8 FLMS EACH D0277 $606.00 512 $424.20 $303.00 $484.80 Non Payable Not Payable Non Payable Non Payable Non Payable Non Payable Non Payable PHARMACY ABACAV/LAMIV/ZIDO TAB 1 TAB $26.33 250 $18.43 $13.16 $21.06 65% 80% 50% 50% 65% 65% 65% PHARMACY ABACAVIR 20 MG/ML ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ABACAVIR TAB 300 MG 1 TAB $17.30 250 $12.11 $8.65 $13.84 65% 80% 50% 50% 65% 65% 65% PHARMACY ABACAVIR/DOLUTEGRAVIR/LAMIVUDINE (TRIUMEQ) 600 MG-50 MG-300 MG TAB 1 TAB $445.46 250 $311.82 $222.73 $356.37 65% 80% 50% 50% 65% 65% 65% PHARMACY ABACAVIR-LAMIVUDINE 600/300 MG TAB 1 TAB $118.50 250 $82.95 $59.25 $94.80 65% 80% 50% 50% 65% 65% 65% PHARMACY ABATACEPT 250 MG INJ - NF J0129 "$5,159.56 " 636 "$3,611.69 " "$2,579.78 " "$4,127.65 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ACARBOSE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAM/ASPIRIN/CAFF 250 MG-250 MG-65 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAM+COD 120/12MG/5ML CUP 5 ML $5.20 250 $3.64 $2.60 $4.16 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAM+COD 360/36MG/15ML LIQ UD 15 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINO-COD 300/30 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN 10 MG/ML INJ 100 ML (SDV) PREMIX - NF 100 ML J0131 $149.22 636 $104.45 $74.61 $119.37 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ACETAMINOPHEN 120 MG SUPP UD 1 SUPP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN 160 MG/5 ML LIQ 5ML UD 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN 160 MG/5 ML SUS UD 1 ML $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ACETAMINOPHEN 160MG/5ML LIQ 20.3 ML UD 20.3 ML $9.97 250 $6.98 $4.98 $7.97 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN 325 MG TAB 100 TAB BTL 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN 325 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN 40MG/1.25 ML LIQ SYRINGE 1.25 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN 500 MG UD TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN 650 MG SUPP 1 SUPP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN-CODEINE 300 MG-30 MG/12.5 ML LIQ UD 12.5 ML $6.12 250 $4.29 $3.06 $4.90 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN-HYDROCODONE 108 MG-2.5 MG/5 ML SOL UD 5 ML $6.17 250 $4.32 $3.08 $4.94 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAMINOPHEN-HYDROCODONE 325 MG-5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAM-OXYCODONE 325-5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETAZOLAMIDE 500 MG INJ 5 ML J1120 $184.63 636 $129.24 $92.31 $147.70 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ACETAZOLAMIDE 250 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETIC ACID OTIC SOLN 2% 15 ML 1 GTT $9.33 250 $6.53 $4.67 $7.47 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETIC ACID TOP 0.25% 250 ML BTL 250 ML $6.81 250 $4.77 $3.40 $5.45 65% 80% 50% 50% 65% 65% 65% PHARMACY "ACETIC ACID TOPICAL 3% SOLN, 30 ML" 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETIC ACID TOPICAL 5% SOL 100 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETYLCHOLINE OPHT 2% INJ 2ML 1 GTT $457.98 250 $320.58 $228.99 $366.38 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETYLCYSTEINE 20% NEB 30ML BTL 30 ML J7608 $42.97 636 $30.08 $21.48 $34.37 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ACETYLCYSTEINE 20% INH 4ML VIAL 1 VIAL J7608 $52.37 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ACETYLCYSTEINE 20% NEB SOLN 10ML BTL 10 ML J7608 $51.03 636 $35.72 $25.52 $40.82 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ACETYLCYSTEINE 600 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACETYLCYSTEINE INJ 20% (SDV) INJ 30ML 30 ML J0132 $26.32 636 $18.42 $13.16 $21.06 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ACITRETIN 10 MG CAP - NF 1 CAP $184.52 250 $129.17 $92.26 $147.62 65% 80% 50% 50% 65% 65% 65% PHARMACY ACITRETIN 25 MG CAP - NF 1 CAP $14.77 250 $10.34 $7.39 $11.82 65% 80% 50% 50% 65% 65% 65% PHARMACY ACYCLOVIR 200 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACYCLOVIR 200 MG/5 ML SUS ORAL SYG 5 ML $5.55 250 $3.88 $2.77 $4.44 65% 80% 50% 50% 65% 65% 65% PHARMACY ACYCLOVIR 400 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ACYCLOVIR 50 MG/ML INJ 1 ML J0133 $5.60 636 $3.92 $2.80 $4.48 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ACYCLOVIR 800 MG TAB U.D. 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ADALIMUMAB 40 MG/0.8 ML (PFS) KIT - NF 0.8 ML J0135 "$12,533.19 " 636 "$8,773.23 " "$6,266.59 " "$10,026.55 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ADEFOVIR 10 MG TAB - NF 1 TAB $217.78 250 $152.45 $108.89 $174.23 65% 80% 50% 50% 65% 65% 65% PHARMACY ADENOSINE 3 MG/ML INJ (SDV) 2ML 2 ML J0153 $26.25 636 $18.38 $13.13 $21.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ADENOSINE 3 MG/ML INJ 20ML VL 1 ML J0153 $504.00 636 $352.80 $252.00 $403.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ADO-TRASTUZUMAB EMTANSINE 100 MG (SDV) INJ - NF 5 ML J9354 "$12,862.96 " 636 "$9,004.07 " "$6,431.48 " "$10,290.36 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ADO-TRASTUZUMAB EMTANSINE 160 MG (SDV) INJ - NF 8 ML J9354 "$20,580.77 " 636 "$14,406.54 " "$10,290.39 " "$16,464.62 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AFLIBERCEPT OPHTHALMIC 40 MG/ML INJ OPHTH - NF 0.05 ML J0178 "$7,770.00 " 636 "$5,439.00 " "$3,885.00 " "$6,216.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AL HYDROXIDE SUS 320MG/5ML ORAL SYR 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AL HYDROXIDE/MG HYDROXIDE/SIMETHICONE 15 ML ORAL SYR 15 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AL HYDROXIDE/MG HYDROXIDE/SIMETHICONE 200 MG-200 MG-20 MG/5 ML SUSP 12 OZ 30 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AL HYDROXIDE/MG HYDROXIDE/SIMETHICONE 30 ML UD CUP 30 ML $13.27 250 $9.29 $6.64 $10.62 65% 80% 50% 50% 65% 65% 65% PHARMACY ALBENDAZOLE 200 MG TAB 1 TAB $27.09 250 $18.96 $13.55 $21.67 65% 80% 50% 50% 65% 65% 65% PHARMACY ALBUMIN HUMAN 25% INJ 100 ML BTL 100 ML P9047 $406.00 636 $284.20 $203.00 $324.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALBUMIN HUMAN 25% INJ 20 ML BTL 20 ML P9047 $126.00 636 $88.20 $63.00 $100.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALBUMIN HUMAN 25% INJ 50 ML BTL 50 ML P9047 $203.00 636 $142.10 $101.50 $162.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALBUMIN HUMAN 5% INJ 250 ML BTL 250 ML P9045 $203.00 636 $142.10 $101.50 $162.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALBUMIN HUMAN 5% INJ 500 ML BTL 500 ML P9045 $438.32 636 $306.83 $219.16 $350.66 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALBUTEROL 0.083% INH 3ML UD 3 ML J7613 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALBUTEROL 0.5% INH 20ML BTL 1 ML J7611 $10.14 636 $7.10 $5.07 $8.11 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALBUTEROL 2 MG TAB 1 TAB $6.88 250 $4.81 $3.44 $5.50 65% 80% 50% 50% 65% 65% 65% PHARMACY ALBUTEROL 2 MG/5 ML ORAL SYG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALBUTEROL HFA 90 MCG/INH AER 1 PUFF $92.65 250 $64.85 $46.32 $74.12 65% 80% 50% 50% 65% 65% 65% PHARMACY ALBUTEROL TAB ER 4 MG 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALBUTEROL-IPRATROPIUM 3 MG-0.5 MG/3 ML SOL UD 3 ML J7620 $8.05 636 $5.64 $4.03 $6.44 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALDESLEUKIN 22000000 UNITS INJ 1 EA J9015 "$9,563.12 " 636 "$6,694.19 " "$4,781.56 " "$7,650.50 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALEMTUZUMAB 30 MG/ML INJ - NF 1 ML J0202 "$2,846.77 " 636 "$1,992.74 " "$1,423.38 " "$2,277.41 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALENDRONATE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALENDRONATE 35 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALENDRONATE 35 MG TAB WEEKLY (NF) 1 TAB $71.71 250 $50.19 $35.85 $57.37 65% 80% 50% 50% 65% 65% 65% PHARMACY ALENDRONATE 70 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALISKIREN 300 MG TAB - NF 1 TAB $24.12 250 $16.88 $12.06 $19.29 65% 80% 50% 50% 65% 65% 65% PHARMACY ALLOPURINOL 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALLOPURINOL 20 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALLOPURINOL 300 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALPRAZOLAM 0.25 MG TAB UD - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALPRAZOLAM 0.5 MG TAB UD - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALPRAZOLAM 1 MG TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALPRAZOLAM 2 MG TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ALPROSTADIL 500 MCG/ML (SDV) INJ 1 ML J0270 $547.55 636 $383.28 $273.77 $438.04 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALTEPLASE 100 MG INJ VL 100 ML J2997 "$36,961.51 " 636 "$25,873.05 " "$18,480.75 " "$29,569.20 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALTEPLASE 2MG (SDV) INJ 2 ML J2997 $642.85 636 $449.99 $321.42 $514.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ALTEPLASE 50 MG INJ VL 50 ML J2997 "$18,480.77 " 636 "$12,936.54 " "$9,240.39 " "$14,784.62 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMANTADINE 100 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMANTADINE 100 MG CAP (NF) 1 CAP $7.41 250 $5.18 $3.70 $5.92 65% 80% 50% 50% 65% 65% 65% PHARMACY AMANTADINE 100 MG TAB 1 TAB $7.99 250 $5.59 $4.00 $6.39 65% 80% 50% 50% 65% 65% 65% PHARMACY AMANTADINE 100MG SYRUP 10ML UD 10 ML $8.99 250 $6.29 $4.49 $7.19 65% 80% 50% 50% 65% 65% 65% PHARMACY AMIKACIN 250 MG/ML (SDV) INJ 4ML 1 ML J0278 $102.94 636 $72.06 $51.47 $82.35 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMIKACIN 5 MG/ML (DIL 1:50 D5W) 1 ML $23.34 250 $16.34 $11.67 $18.67 65% 80% 50% 50% 65% 65% 65% PHARMACY AMILORIDE 5 MG TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINO ACIDS 10% (TROPHAMINE) 500 ML 500 ML $365.06 250 $255.54 $182.53 $292.05 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINO ACIDS 10% (FREAMINE III) IV SOLN 1000 ML $69.16 250 $48.41 $34.58 $55.33 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINO ACIDS 10% INJ (TRAVASOL) 2000 ML BTL 2000 ML $423.65 250 $296.56 $211.83 $338.92 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINO ACIDS 15% (AMINOSYN II SULFITE-FREE) SOL 2000 ML 2000 ML $177.38 250 $124.17 $88.69 $141.90 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINO ACIDS 15% (CLINISOL SULFITE-FREE) SOL 2000 ML 2000 ML $514.36 250 $360.05 $257.18 $411.49 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINO ACIDS 15% (CLINISOL SULFITE-FREE) SOL 500 ML 500 ML $365.16 250 $255.61 $182.58 $292.12 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINO ACIDS 8% INJ 500 ML BTL 500 ML $637.22 250 $446.05 $318.61 $509.78 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINOCAPROIC ACID 10 MG/ML (DIL 1:25 D5W) 1 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINOCAPROIC ACID 1000 MG TAB - NF 1 TAB $141.14 250 $98.79 $70.57 $112.91 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINOCAPROIC ACID 25% ORAL SYG 5 ML $248.18 250 $173.73 $124.09 $198.54 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINOCAPROIC ACID 250 MG/ML INJ 20 ML VL 1 ML $37.80 250 $26.46 $18.90 $30.24 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINOCAPROIC ACID 500 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMINOLEVULINIC ACID TOPICAL 20% SOL 1 EA J7308 $459.00 636 $321.30 $229.50 $367.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMINOPHYLLINE 25 MG/ML (SDV) INJ 20 ML J0280 $48.02 636 $33.61 $24.01 $38.41 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMIODARONE 200 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMIODARONE 50 MG/ML (SDV) INJ 3 ML 3 ML J0282 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMISULPRIDE 5 MG/2 ML (SDV) INJ 2 ML $89.25 250 $62.48 $44.63 $71.40 65% 80% 50% 50% 65% 65% 65% PHARMACY AMITRIPTYLINE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMITRIPTYLINE 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMITRIPTYLINE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMITRIPTYLINE 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMITRIPTYLINE 75 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMLODIPINE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMLODIPINE 1MG/ML ORAL SYR 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMLODIPINE 2.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMLODIPINE 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMMONIA INH 0.33 ML 1 INHALATION $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMMONIUM LACTATE TOPICAL 12% CREAM 140 GM (NF) 1 APP $48.82 250 $34.18 $24.41 $39.06 65% 80% 50% 50% 65% 65% 65% PHARMACY AMMONIUM LACTATE TOPICAL 12% LOT 225ML BTL 1 APP $63.84 250 $44.69 $31.92 $51.07 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOX-CLAV 500/125 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOXICILLIN 125 MG/5 ML ORAL SYG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOXICILLIN 250 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOXICILLIN 250 MG CHEW TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOXICILLIN 250 MG/5 ML 150 ML BTL 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOXICILLIN 250 MG/5 ML ORAL SYG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOXICILLIN 500 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOXICILLIN-CLAV 250MG/5ML ORAL SYG 5 ML $14.82 250 $10.37 $7.41 $11.85 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOXICILLIN-CLAVULANATE 600 MG-42.9 MG/5 ML SUSP 5 ML $181.41 250 $126.98 $90.70 $145.12 65% 80% 50% 50% 65% 65% 65% PHARMACY AMOXICILLIN-CLAVULANATE 875 MG-125 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHETAMINE-DEXTROAMPHETAMINE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHETAMINE-DEXTROAMPHETAMINE 5 MG TAB 1 TAB $6.00 250 $4.20 $3.00 $4.80 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHETAMINE-DEXTROAMPHETAMINE ER 10 MG CAP 1 CAP $21.47 250 $15.03 $10.74 $17.18 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHETAMINE-DEXTROAMPHETAMINE ER 15 MG CAP 1 CAP $21.46 250 $15.02 $10.73 $17.17 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHETAMINE-DEXTROAMPHETAMINE ER 20 MG CAP 1 CAP $21.46 250 $15.02 $10.73 $17.17 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHETAMINE-DEXTROAMPHETAMINE ER 25 MG CAP 1 CAP $21.46 250 $15.02 $10.73 $17.17 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHETAMINE-DEXTROAMPHETAMINE ER 30 MG CAP 1 CAP $21.46 250 $15.02 $10.73 $17.17 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHETAMINE-DEXTROAMPHETAMINE ER 5 MG CAP 1 CAP $21.46 250 $15.02 $10.73 $17.17 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHOTERICIN 1 MG/5 ML ORAL SYRG (PED) 5 ML $7.16 250 $5.01 $3.58 $5.73 65% 80% 50% 50% 65% 65% 65% PHARMACY AMPHOTERICIN B 0.1 MG/ML (DIL 1:50 D5W) 1 ML J0285 $159.60 636 $111.72 $79.80 $127.68 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPHOTERICIN B 50 MG INJ VL 10 ML J0285 $191.21 636 $133.84 $95.60 $152.96 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPHOTERICIN B LIPOSOMAL (AMBISOME) 50 MG VL (SDV) J0289 "$1,122.63 " 636 $785.84 $561.31 $898.10 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPHOTERICIN B LIPOSOMAL 1 MG/ML (DIL 1:4 D5W) 1 ML J0289 "$1,038.00 " 636 $726.60 $519.00 $830.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPICILLIN 1 GM INJ VL 4 ML J0290 $287.18 636 $201.02 $143.59 $229.74 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPICILLIN 100 MG/ML (DIL 1:2.5 SWFI) 2.5 ML J0290 $146.51 636 $102.56 $73.26 $117.21 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPICILLIN 1000 MG / SULBACTAM 500 MG INJ VL J0295 $319.13 636 $223.39 $159.57 $255.30 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPICILLIN 2 GM INJ VL 8 ML J0290 $586.36 636 $410.45 $293.18 $469.08 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPICILLIN 2000 MG / SULBACTAM 1000 MG INJ VL J0295 $537.95 636 $376.57 $268.98 $430.36 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPICILLIN 500 MG (100 MG/ML) INJ 5 ML J0290 $154.21 636 $107.95 $77.11 $123.37 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AMPICILLIN-SULBACTAM 30 MG/ML (DIL 1:8.3 NS) 1 ML J0295 $31.91 636 $22.34 $15.96 $25.53 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ANAGRELIDE 0.5 MG CAP - NF 1 CAP $39.07 250 $27.35 $19.54 $31.26 65% 80% 50% 50% 65% 65% 65% PHARMACY ANAKINRA 100 MG/0.67 ML SOL - NF 0.67 ML $971.69 250 $680.19 $485.85 $777.36 65% 80% 50% 50% 65% 65% 65% PHARMACY ANASTROZOLE 1 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ANASTROZOLE 1 MG TAB UD (NF) 1 TAB $47.18 250 $33.03 $23.59 $37.75 65% 80% 50% 50% 65% 65% 65% PHARMACY ANIDULAFUNGIN 100 MG (SDV) INJ - NF J0348 $756.00 636 $529.20 $378.00 $604.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ANIFROLUMAB FNIA 300 MG/2 ML SOL 1 VIAL J0491 "$5,390.60" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ANTIHEMOPHILIC FACTOR 8 RECOMB ALBUMIN-FREE 3000 INTERNATIONAL UNITS INJ - NF 1 VIAL J7192 $7.31 636 $5.12 $3.65 $5.85 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ANTIHEMOPHILIC FACTOR VIIA (NOVO SEVEN) 1000 MCG (SDV) 1 VIAL J7189 "$9,408.00 " 636 "$6,585.60 " "$4,704.00 " "$7,526.40 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ANTIHEMOPHILIC FACTOR VIIA (NOVO SEVEN) 5000 MCG (SDV) 1 VIAL J7189 "$47,040.00 " 636 "$32,928.00 " "$23,520.00 " "$37,632.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ANTIHEMOPHILIC FACTOR VIII INJ (RECOMBINANTE/KOGENATE) 1 EA J7192 "$7,476.00 " 636 "$5,233.20 " "$3,738.00 " "$5,980.80 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ANTIHEMOPHILIC FACTOR VWF (HUMATE-P) J7186 "$8,400.00 " 636 "$5,880.00 " "$4,200.00 " "$6,720.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ANTI-INHIBITOR COAGULANT COMPLEX - PWD (FEIBA) J7198 $10.04 636 $7.03 $5.02 $8.03 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ANTI-THYMOCYTE GLOBULIN (RABBIT) 25 MG POW J7511 "$3,862.78 " 636 "$2,703.94 " "$1,931.39 " "$3,090.22 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY APIXABAN 2.5 MG TAB UD 1 TAB $34.94 250 $24.46 $17.47 $27.95 65% 80% 50% 50% 65% 65% 65% PHARMACY APIXABAN 5 MG TAB UD 1 TAB $34.94 250 $24.46 $17.47 $27.95 65% 80% 50% 50% 65% 65% 65% PHARMACY APRACLONIDINE OP SOL 1% 0.1ML UD 1 GTT $116.46 250 $81.52 $58.23 $93.17 65% 80% 50% 50% 65% 65% 65% PHARMACY APREPITANT 125 MG-80 MG KIT 1 KIT J8501 $841.45 636 $589.01 $420.72 $673.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ARGATROBAN 100 MG/ML (NON ESRD) (SDV) INJ 1 ML J0883 "$1,356.60 " 636 $949.62 $678.30 "$1,085.28 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ARIPIPRAZOLE 1 MG/ML SOL 1 ML $24.73 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ARIPIPRAZOLE 10 MG TAB UD 1 TAB $23.55 250 $16.49 $11.78 $18.84 65% 80% 50% 50% 65% 65% 65% PHARMACY ARIPIPRAZOLE 15 MG TAB 1 TAB $108.17 250 $75.72 $54.09 $86.54 65% 80% 50% 50% 65% 65% 65% PHARMACY ARIPIPRAZOLE 2 MG TAB 1 TAB $96.15 250 $67.31 $48.08 $76.92 65% 80% 50% 50% 65% 65% 65% PHARMACY ARIPIPRAZOLE 20 MG TAB 1 TAB $158.92 250 $111.24 $79.46 $127.14 65% 80% 50% 50% 65% 65% 65% PHARMACY ARIPIPRAZOLE 400 MG INJ J0401 "$10,031.56 " 636 "$7,022.09 " "$5,015.78 " "$8,025.25 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ARIPIPRAZOLE 5 MG TAB UD 1 TAB $12.60 250 $8.82 $6.30 $10.08 65% 80% 50% 50% 65% 65% 65% PHARMACY ARMODAFINIL 150 MG TAB - NF 1 TAB $118.89 250 $83.22 $59.44 $95.11 65% 80% 50% 50% 65% 65% 65% PHARMACY ARMODAFINIL 250 MG TAB - NF 1 TAB $76.52 250 $53.57 $38.26 $61.22 65% 80% 50% 50% 65% 65% 65% PHARMACY ARSENIC TRIOXIDE 1 MG/ML INJ (SDV) - NF 10 ML J9017 $236.14 636 $165.30 $118.07 $188.91 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ARSENIC TRIOXIDE 2 MG/ML INJ (SDV) - NF 6 ML J9017 $625.46 636 $437.83 $312.73 $500.37 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ARTEMETHER-LUMEFANTRINE 20 MG-120 MG TAB 1 TAB $21.46 250 $15.02 $10.73 $17.17 65% 80% 50% 50% 65% 65% 65% PHARMACY ARTICAINE-EPINEPHRINE 4%-1:100000 SOL 1.7 ML $20.00 250 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% PHARMACY ASCORBIC ACID 500 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ASCORBIC ACID 500 MG/ML INJ - FOR TPN USE 1 ML "$1,033.20 " 250 $723.24 $516.60 $826.56 65% 80% 50% 50% 65% 65% 65% PHARMACY ASENAPINE 10 MG TAB UD (NF) 1 TAB $43.89 250 $30.72 $21.94 $35.11 65% 80% 50% 50% 65% 65% 65% PHARMACY ASPIRIN 300 MG SUP UD 1 SUPP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ASPIRIN 325 MG EC TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ASPIRIN 600 MG SUP UD 1 SUPP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ASPIRIN 81 MG CHEW TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ASPIRIN EC 81 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ATAZANAVIR 150 MG CAP 1 CAP $33.65 250 $23.55 $16.82 $26.92 65% 80% 50% 50% 65% 65% 65% PHARMACY ATAZANAVIR 200 MG CAP 1 CAP $33.65 250 $23.55 $16.82 $26.92 65% 80% 50% 50% 65% 65% 65% PHARMACY ATAZANAVIR 300 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ATENOLOL 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ATENOLOL 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ATENOLOL 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ATEZOLIZUMAB 1200 MG/20 ML INJ (SDV) 20 ML J9022 "$1,892.89 " 636 "$1,325.02 " $946.44 "$1,514.31 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATEZOLIZUMAB 840 MG/14 ML (SDV) INJ 14 ML J9022 "$10,093.89 " 636 "$7,065.73 " "$5,046.95 " "$8,075.12 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATOMOXETINE 10 MG CAP - NF 1 CAP $55.36 250 $38.75 $27.68 $44.28 65% 80% 50% 50% 65% 65% 65% PHARMACY ATOMOXETINE 18 MG CAP - NF 1 CAP $55.36 250 $38.75 $27.68 $44.28 65% 80% 50% 50% 65% 65% 65% PHARMACY ATOMOXETINE 25 MG CAP - NF 1 CAP $55.36 250 $38.75 $27.68 $44.28 65% 80% 50% 50% 65% 65% 65% PHARMACY ATOMOXETINE 40 MG CAP - NF 1 CAP $60.14 250 $42.10 $30.07 $48.12 65% 80% 50% 50% 65% 65% 65% PHARMACY ATOMOXETINE 80 MG CAP - NF 1 CAP $64.89 250 $45.42 $32.45 $51.91 65% 80% 50% 50% 65% 65% 65% PHARMACY ATORVASTATIN 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ATORVASTATIN 20 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ATORVASTATIN 40 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ATORVASTATIN 80 MG TAB UD 1 TAB $6.86 250 $4.80 $3.43 $5.49 65% 80% 50% 50% 65% 65% 65% PHARMACY ATOVAQUONE 750 MG/5 ML ORAL SYG 5 ML $114.85 250 $80.40 $57.43 $91.88 65% 80% 50% 50% 65% 65% 65% PHARMACY ATOVAQUONE 750 MG/5 ML SUS UD (NF) 5 ML $27.85 250 $19.50 $13.93 $22.28 65% 80% 50% 50% 65% 65% 65% PHARMACY ATOVAQUONE-PROGUANIL 250 MG-100 MG TAB - NF 1 TAB $28.84 250 $20.19 $14.42 $23.07 65% 80% 50% 50% 65% 65% 65% PHARMACY ATRACURIUM 10 MG/ML INJ 5 ML VL 5 ML $33.60 250 $23.52 $16.80 $26.88 65% 80% 50% 50% 65% 65% 65% PHARMACY ATRIPLA - EFAVIRENZ/EMTRICITABINE/TENOFOVIR 600 MG-200 MG-300 MG TAB 1 TAB $96.36 250 $67.45 $48.18 $77.08 65% 80% 50% 50% 65% 65% 65% PHARMACY "ATROPINE 0.05 MG/ML INJ, 5 ML SYR" 5 ML J0461 $58.23 636 $40.76 $29.11 $46.58 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATROPINE 100 MCG/ML INJ 10ML SYG 1 SYRINGE J0461 $4.20 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATROPINE 100MCG/ML INJ 10ML SYG 10 ML J0461 $43.76 636 $30.63 $21.88 $35.01 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATROPINE 100MCG/ML INJ 5ML SYR 5 ML J0461 $38.14 636 $26.70 $19.07 $30.51 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATROPINE 1MG/ML INJ 1 ML AMP 1 ML J0461 $52.75 636 $36.93 $26.38 $42.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATROPINE 400 MCG/ML INJ 1ML VL 1 VIAL J0461 $45.36 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATROPINE 400 MCG/ML INJ 20ML VL 1 ML J0461 $147.42 636 $103.19 $73.71 $117.94 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATROPINE 400MCG/ML INJ 1ML VL 1 ML J0461 $33.60 636 $23.52 $16.80 $26.88 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ATROPINE OPHT 1% OIN 3.5 GM TU 0.5 INCH $73.54 250 $51.47 $36.77 $58.83 65% 80% 50% 50% 65% 65% 65% PHARMACY ATROPINE OPHT 1% OINT - OPHTH 0.5 INCH $19.27 250 $13.49 $9.64 $15.42 65% 80% 50% 50% 65% 65% 65% PHARMACY ATROPINE OPHTHALMIC 1% SOL - OPHTH 1 GTT $53.81 250 $37.67 $26.91 $43.05 65% 80% 50% 50% 65% 65% 65% PHARMACY ATROPINE OPHTHALMIC 1% SOL 2ML BTL 1 GTT $167.51 250 $117.26 $83.76 $134.01 65% 80% 50% 50% 65% 65% 65% PHARMACY ATROPINE OPHTHALMIC 1% SOL 5ML BTL 1 GTT $204.33 250 $143.03 $102.17 $163.46 65% 80% 50% 50% 65% 65% 65% PHARMACY ATROPINE+EDROPHONIUM CL INJ 1 ML $92.40 250 $64.68 $46.20 $73.92 65% 80% 50% 50% 65% 65% 65% PHARMACY ATROPINE-DIPHENOXYLATE LIQ ORAL SYG 5 ML $24.50 250 $17.15 $12.25 $19.60 65% 80% 50% 50% 65% 65% 65% PHARMACY AURANOFIN 3 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AVELUMAB 20 MG/ML INJ 10 ML VL 10 ML J9023 "$56,455.20 " 636 "$39,518.64 " "$28,227.60 " "$45,164.16 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AZACITIDINE 100 MG PWD INJ (SDV) 10 ML J9025 "$2,161.67 " 636 "$1,513.17 " "$1,080.84 " "$1,729.34 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AZATHIOPRINE 50 MG TAB UD 1 TAB J7500 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AZELASTINE OPHTHALMIC 0.05% SOLN 6ML BTL 1 GTT $364.25 250 $254.97 $182.12 $291.40 65% 80% 50% 50% 65% 65% 65% PHARMACY AZITHROMYCIN 100 MG/5 ML ORAL SYRG 5 ML $40.69 250 $28.49 $20.35 $32.55 65% 80% 50% 50% 65% 65% 65% PHARMACY AZITHROMYCIN 2 MG/ML (DIL 1:50 NS) 1 ML J0456 $31.22 636 $21.85 $15.61 $24.98 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AZITHROMYCIN 200 MG/5 ML ORAL SYR 5 ML $20.35 250 $14.24 $10.17 $16.28 65% 80% 50% 50% 65% 65% 65% PHARMACY AZITHROMYCIN 250 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY AZITHROMYCIN 500 MG (SDV) INJ 10 ML J0456 $252.00 636 $176.40 $126.00 $201.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AZITHROMYCIN 500 MG TAB UD 1 TAB $5.86 250 $4.10 $2.93 $4.68 65% 80% 50% 50% 65% 65% 65% PHARMACY AZITHROMYCIN 500 MG/250 ML D5W IVPB PREMADE KIT 250 ML J0456 $72.80 636 $50.96 $36.40 $58.24 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY AZITHROMYCIN 600 MG TAB 1 TAB $8.73 250 $6.11 $4.36 $6.98 65% 80% 50% 50% 65% 65% 65% PHARMACY AZTREONAM 1GM INJ VL 5 ML "$1,218.00 " 250 $852.60 $609.00 $974.40 65% 80% 50% 50% 65% 65% 65% PHARMACY AZTREONAM 1GM/100 ML D5W - PREMADE KIT 100 ML $92.68 250 $64.88 $46.34 $74.14 65% 80% 50% 50% 65% 65% 65% PHARMACY AZTREONAM 2 GM INJ VL 10 ML "$3,079.02 " 250 "$2,155.31 " "$1,539.51 " "$2,463.22 " 65% 80% 50% 50% 65% 65% 65% PHARMACY AZTREONAM 2GM/100 ML D5W - PREMADE KIT 100 ML $281.19 250 $196.83 $140.60 $224.95 65% 80% 50% 50% 65% 65% 65% PHARMACY BACILLUS CALMETTE GUERIN (BCG) FOR INTRAVESICAL USE 0.33 ML J9030 $217.69 636 $152.39 $108.85 $174.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BACITRACIN OIN 30GM TUBE 1 APP $12.14 250 $8.50 $6.07 $9.72 65% 80% 50% 50% 65% 65% 65% PHARMACY BACITRACIN 50000 UNITS INJ VL 10 ML $420.00 250 $294.00 $210.00 $336.00 65% 80% 50% 50% 65% 65% 65% PHARMACY BACITRACIN OINT 500 UNITS/G PKT 1 APP $116.55 250 $81.59 $58.28 $93.24 65% 80% 50% 50% 65% 65% 65% PHARMACY BACITRACIN OPHTHALMIC OINT - OPHTH 0.5 INCH $112.80 250 $78.96 $56.40 $90.24 65% 80% 50% 50% 65% 65% 65% PHARMACY BACITRACIN OPHTHALMIC OINT 3.5 GM TU 0.5 INCH $417.13 250 $291.99 $208.57 $333.70 65% 80% 50% 50% 65% 65% 65% PHARMACY BACITRACIN TOPICAL ZINC 500 UNITS/G OIN UD 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BACITRACIN-POLYMYXIN B TOPICAL 500 UNITS-10000 UNITS/G OIN UD 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BACLOFEN 0.05 MG/ML IT INJ - NF 1 ML J0476 $369.25 636 $258.48 $184.63 $295.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BACLOFEN 0.5 MG/ML IT INJ 20ML SYR - NF 1 ML J0475 "$1,066.24 " 636 $746.37 $533.12 $852.99 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BACLOFEN 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BACLOFEN 10 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BACLOFEN IT 1 MG/ML INJ 1 ML J0475 $81.18 636 $56.83 $40.59 $64.94 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BACLOFEN IT 2 MG/ML INJ - NF 1 ML J0476 "$4,269.65 " 636 "$2,988.76 " "$2,134.83 " "$3,415.72 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BALANCED SALT OPHT SOL 15ML BTL 1 APP $42.88 250 $30.02 $21.44 $34.31 65% 80% 50% 50% 65% 65% 65% PHARMACY BALANCED SALT OPHT SOL 500ML BAG 500 ML $124.83 250 $87.38 $62.41 $99.86 65% 80% 50% 50% 65% 65% 65% PHARMACY BALANCED SALT SOLN PLUS OPH 500ML 500 ML $324.45 250 $227.12 $162.23 $259.56 65% 80% 50% 50% 65% 65% 65% PHARMACY BALOXAVIR MARBOXIL 40 MG TAB 1 EA $668.39 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BALOXAVIR MARBOXIL 80 MG TAB 1 EA $668.39 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BALSALAZIDE 750 MG CAP UD - NF 1 CAP $9.23 250 $6.46 $4.62 $7.38 65% 80% 50% 50% 65% 65% 65% PHARMACY BARICITINIB 1 MG TAB - NF 1 TAB $332.98 250 $233.08 $166.49 $266.38 65% 80% 50% 50% 65% 65% 65% PHARMACY BARICITINIB 2 MG TAB - NF 1 TAB $332.98 250 $233.08 $166.49 $266.38 65% 80% 50% 50% 65% 65% 65% PHARMACY BECAPLERMIN TOPICAL 0.01% GEL - NF 1 APP "$5,179.86 " 250 "$3,625.90 " "$2,589.93 " "$4,143.89 " 65% 80% 50% 50% 65% 65% 65% PHARMACY BELANTAMAB MAFODOTIN 100 MG (SDV) INJ - NF J9037 "$18,582.55 " 636 "$13,007.79 " "$9,291.28 " "$14,866.04 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BELIMUMAB 120 MG (SDV) INJ - NF 1.5 ML J0490 "$2,344.69 " 636 "$1,641.28 " "$1,172.35 " "$1,875.75 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BELIMUMAB 400 MG (SDV) INJ - NF 5 ML J0490 "$7,815.36 " 636 "$5,470.75 " "$3,907.68 " "$6,252.29 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BENAZEPRIL 10 MG TAB UD - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BENAZEPRIL 20 MG TAB UD - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BENAZEPRIL 40 MG TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BENAZEPRIL 5 MG TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BENDAMUSTINE 100 MG (TREANDA) (SDV) INJ J9033 "$1,601.68 " 636 "$1,121.17 " $800.84 "$1,281.34 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BENDAMUSTINE 100 MG/4 ML (BENDEKA) INJ 4 ML J9034 "$2,597.49 " 636 "$1,818.24 " "$1,298.75 " "$2,077.99 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BENDAMUSTINE 180 MG/2 ML (TREANDA) INJ 2 ML 2 ML J9033 "$6,784.59 " 636 "$4,749.21 " "$3,392.30 " "$5,427.67 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BENDAMUSTINE 25 MG (TREANDA) (SDV) INJ J9033 $475.43 636 $332.80 $237.72 $380.34 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BENDAMUSTINE 45 MG/0.5 ML (TREANDA) INJ 0.5 ML 0.5 ML J9033 "$1,758.32 " 636 "$1,230.82 " $879.16 "$1,406.65 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BENOXINATE-FLUORESCEIN OPHTHALMIC 0.4%-0.3% SOL 1 EA $26.88 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BENZOCAINE TOPICAL 20% SPR 60GM BTL 1 SPRAY $137.20 250 $96.04 $68.60 $109.76 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZOCAINE/BUTAMBEN/TETRACAINE DENTAL 14%-2%-2% SPR 1 EA $8.75 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BENZOCAINE/BUTAMBEN/TETRACAINE TOPICAL 14%-2%-2% INH 1 SPRAY $8.75 250 $6.13 $4.38 $7.00 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZOCAINE-MENTHOL TOPICAL 15 MG-2.6 MG LOZ 1 LOZENGE $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZOIN TOPICAL COMPOUND TIN 60 ML 60 ML $18.65 250 $13.05 $9.32 $14.92 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZOYL PEROXIDE 5% GEL 45GM TU 1 APP $19.88 250 $13.92 $9.94 $15.90 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZOYL PEROXIDE 10% GEL 45GM TU 1 APP $24.19 250 $16.93 $12.09 $19.35 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZOYL PEROXIDE TOPICAL 5% GEL 60GM 1 APP $70.88 250 $49.61 $35.44 $56.70 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZOYL PEROXIDE TOPICAL 5% LOTION 1 APP $10.57 250 $7.40 $5.28 $8.46 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZTROPINE 0.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZTROPINE 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZTROPINE 1 MG/ML INJ 2ML AMP 2 ML J0515 $262.50 636 $183.75 $131.25 $210.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BENZTROPINE 2 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BENZYLPENICILLOYL-POLYLYSINE INJ 0.25 ML "$2,496.48 " 250 "$1,747.54 " "$1,248.24 " "$1,997.18 " 65% 80% 50% 50% 65% 65% 65% PHARMACY BETAMETHASONE ACETATE 3MG/BETAMETHASONE SOD PHOSPHATE 3MG 5 ML J0702 $220.12 636 $154.08 $110.06 $176.09 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BETHANECHOL 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BETHANECHOL 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BEVACIZUMAB 2.5 MG/0.1 ML INJ SYR OPHTH 0.1 ML C9257 $620.63 636 $434.44 $310.32 $496.50 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BEVACIZUMAB 25 MG/ML 16ML (SDV) 16 ML J9035 "$4,721.95 " 636 "$3,305.36 " "$2,360.97 " "$3,777.56 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BEVACIZUMAB 25 MG/ML INJ 4ML (SDV) 4 ML J9035 "$1,148.15 " 636 $803.70 $574.07 $918.52 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BEVACIZUMAB OPHTHALMIC 2.5 MG/0.1 ML SOL 1 EA C9257 "$2,568.65" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BEVACIZUMAB-BVZR (ZIRABEV) 25 MG/ML INJ (SDV) 16 ML VL - NF 16 ML Q5118 "$2,447.40 " 636 "$1,713.18 " "$1,223.70 " "$1,957.92 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BEVACIZUMAB-BVZR (ZIRABEV) 25 MG/ML INJ (SDV) 4 ML VL - NF 4 ML Q5118 $686.85 636 $480.80 $343.43 $549.48 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BICALUTAMIDE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BICTEGRAVIR/EMTRICITABINE/TENOFOVIR (BIKTARVY) 50 MG-200 MG-25 MG TAB 1 TAB $475.13 250 $332.59 $237.56 $380.10 65% 80% 50% 50% 65% 65% 65% PHARMACY BIMATOPROST OPHTHALMIC 10 MCG IMPLANT J7351 "$8,190.00 " 636 "$5,733.00 " "$4,095.00 " "$6,552.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BIOTIN 5 MG CAP - NF 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BISACODYL 10 MG SUPP UD 1 SUPP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BISACODYL 5 MG EC TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BISMUTH SUBSALICYLATE SUSP 120ML 15 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BISMUTH SUBSALICYLATE SUSP ORAL SYR 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BISMUTH TRIBROMOPHENATE GAUZE 3% 4X3 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BISMUTH TRIBROMOPHENATE GAUZE 3% 5X9 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BIVALIRUDIN 250 MG (SDV) INJ J0583 "$11,550.00 " 636 "$8,085.00 " "$5,775.00 " "$9,240.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BLEOMYCIN 15 UNITS INJ J9040 $137.44 636 $96.21 $68.72 $109.96 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BLEOMYCIN 30 UNITS INJ J9040 $445.62 636 $311.93 $222.81 $356.50 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BLINATUMOMAB 35 MCG INJ (SDV) - NF 2.8 ML J9039 "$17,816.82 " 636 "$12,471.77 " "$8,908.41 " "$14,253.46 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BLOOD GLUCOSE TEST STRIPS 1 EA $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BORIC ACID TOPICAL POWDER 1 APP $61.19 250 $42.83 $30.59 $48.95 65% 80% 50% 50% 65% 65% 65% PHARMACY BORTEZOMIB 3.5 MG PWD INJ (SDV) J9041 "$2,295.82 " 636 "$1,607.07 " "$1,147.91 " "$1,836.66 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BOSENTAN 62.5 MG TAB - NF $173.25 250 $121.28 $86.63 $138.60 65% 80% 50% 50% 65% 65% 65% PHARMACY BRENTUXIMAB VEDOTIN 50 MG (SDV) - NF J9042 "$7,243.66 " 636 "$5,070.56 " "$3,621.83 " "$5,794.93 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BRIMONIDINE OPHTHALMIC 0.2% SOL 5ML BTL 1 GTT $8.75 250 $6.13 $4.38 $7.00 65% 80% 50% 50% 65% 65% 65% PHARMACY BRIMONIDINE OPHTHALMIC 0.2% SOL OPHTH 1 GTT $12.92 250 $9.04 $6.46 $10.33 65% 80% 50% 50% 65% 65% 65% PHARMACY BRIMONIDINE-TIMOLOL OPHTHALMIC 0.2%-0.5% SOL 1 BTL $171.46 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BRIVARACETAM 100 MG TAB UD 1 TAB $85.03 250 $59.52 $42.52 $68.03 65% 80% 50% 50% 65% 65% 65% PHARMACY BROMOCRIPTINE 2.5 MG TAB 1 TAB $13.35 250 $9.35 $6.68 $10.68 65% 80% 50% 50% 65% 65% 65% PHARMACY BROMOCRIPTINE 2.5 MG TAB 1 TAB $21.94 250 $15.36 $10.97 $17.55 65% 80% 50% 50% 65% 65% 65% PHARMACY BROMOCRIPTINE 5 MG CAP 1 CAP $32.59 250 $22.81 $16.29 $26.07 65% 80% 50% 50% 65% 65% 65% PHARMACY BUDESONIDE (PULMICORT FLEXHALER) 180 MCG/INH DPI 1 PUFF "$1,078.95 " 250 $755.26 $539.47 $863.16 65% 80% 50% 50% 65% 65% 65% PHARMACY BUDESONIDE 0.25 MG/2 ML NEB SOLN 2 ML J7626 $32.93 636 $23.05 $16.46 $26.34 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUDESONIDE 0.5 MG/2 ML NEB SOLN 2 ML J7633 $19.39 636 $13.57 $9.69 $15.51 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUDESONIDE 3 MG ENTERIC COATED - NF 1 CAP $96.66 250 $67.66 $48.33 $77.33 65% 80% 50% 50% 65% 65% 65% PHARMACY BUDESONIDE-FORMOTEROL 160 MCG-4.5 MCG/INH AER 1 PUFF "$1,060.75 " 250 $742.52 $530.37 $848.60 65% 80% 50% 50% 65% 65% 65% PHARMACY BUDESONIDE-FORMOTEROL 80 MCG-4.5 MCG/INH AER 1 PUFF $133.64 250 $93.55 $66.82 $106.91 65% 80% 50% 50% 65% 65% 65% PHARMACY BUMETANIDE 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BUMETANIDE 2 MG TAB 1 TAB $7.20 250 $5.04 $3.60 $5.76 65% 80% 50% 50% 65% 65% 65% PHARMACY BUMETANIDE 250 MCG/ML (SDV) 4 ML INJ 1 ML $11.85 250 $8.30 $5.93 $9.48 65% 80% 50% 50% 65% 65% 65% PHARMACY BUMETANIDE 250 MCG/ML INJ 10ML VL 10 ML $12.87 250 $9.01 $6.43 $10.30 65% 80% 50% 50% 65% 65% 65% PHARMACY BUMETANIDE 500 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPIVACAINE 0.0625% W FENTANYL 2 MCG/ML EPIDURAL/PCEA INJ 50 ML 50 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPIVACAINE 0.25% PF INJ 10 ML 1 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPIVACAINE 0.25% PF INJ 30 ML 1 ML $11.20 250 $7.84 $5.60 $8.96 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPIVACAINE 0.5% PF INJ 10 ML 1 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPIVACAINE 0.5% PF INJ 30 ML 30 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPIVACAINE0.75%-D8.25% PF INJ 2ML 2 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY "BUPIVACAINE-EPINEPHRINE 0.25%-1:200,000 PRESERVATIVE-FREE SOL" 30 ML $35.24 250 $24.67 $17.62 $28.19 65% 80% 50% 50% 65% 65% 65% PHARMACY "BUPIVACAINE-EPINEPHRINE 0.5%-1:200,000 PF INJ" 30 ML $37.97 250 $26.58 $18.98 $30.37 65% 80% 50% 50% 65% 65% 65% PHARMACY "BUPIVACAINE-EPINEPHRINE 0.5%-1:200,000 DENTAL CARTRIDGE" 1.8 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPRENORPHINE 100 MG/0.5 ML ERS 0.5 ML Q9991 "$16,132.20" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPRENORPHINE 150 MCG BUCCAL FILM STRIP $26.92 250 $18.84 $13.46 $21.54 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPRENORPHINE 2 MG SL TAB 1 TAB J0571 $15.75 636 $11.03 $7.88 $12.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPRENORPHINE 300 MG/1.5 ML ERS 1.5 ML Q9992 "$5,377.40" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPRENORPHINE 450 MCG BUCCAL FILM STRIP $57.45 250 $40.21 $28.72 $45.96 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPRENORPHINE 8 MG SL TAB 1 TAB J0571 $14.70 636 $10.29 $7.35 $11.76 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPRENORPHINE 900 MCG BUCCAL FILM STRIP $66.36 250 $46.45 $33.18 $53.08 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPRENORPHINE-NALOXONE 12 MG-3 MG STRIP 1 EA J0575 $61.60 636 $43.12 $30.80 $49.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPRENORPHINE-NALOXONE 2 MG-0.5 MG STRIP 1 EA J0572 $21.04 636 $14.73 $10.52 $16.83 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPRENORPHINE-NALOXONE 2 MG-0.5 MG TAB 1 TAB J0572 $20.39 636 $14.27 $10.19 $16.31 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPRENORPHINE-NALOXONE 4 MG-1 MG STRIP 1 EA J0573 $30.80 636 $21.56 $15.40 $24.64 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPRENORPHINE-NALOXONE 8 MG-2 MG STRIP 1 EA J0574 $30.80 636 $21.56 $15.40 $24.64 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPRENORPHINE-NALOXONE 8 MG-2 MG TAB 1 TAB J0574 $29.59 636 $20.72 $14.80 $23.68 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUPROPION 100 MG TAB - NF 1 TAB $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPROPION 100 MG/12 HOURS SR TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPROPION 150MG/12 HOURS SR TAB (WELLBUT) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPROPION 300 MG/24 HOURS ER UD 1 TAB $22.04 250 $15.43 $11.02 $17.63 65% 80% 50% 50% 65% 65% 65% PHARMACY BUPROPION XL 150 MG/24 HOURS ER TAB 1 TAB $16.30 250 $11.41 $8.15 $13.04 65% 80% 50% 50% 65% 65% 65% PHARMACY BUSPIRONE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BUSPIRONE 15 MG TAB 1 TAB $7.40 250 $5.18 $3.70 $5.92 65% 80% 50% 50% 65% 65% 65% PHARMACY BUSPIRONE 30 MG TAB 1 TAB $12.72 250 $8.91 $6.36 $10.18 65% 80% 50% 50% 65% 65% 65% PHARMACY BUSPIRONE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BUSPIRONE 7.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY BUSULFAN 2 MG TAB 1 TAB J8510 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY BUTORPHANOL 2000 MCG/ML INJ 1 ML J0595 $22.42 636 $15.70 $11.21 $17.94 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CABAZITAXEL 60 MG/1.5 ML (SDV) DILUTED TO 10 MG/ML INJ 6 ML J9043 "$33,951.46 " 636 "$23,766.02 " "$16,975.73 " "$27,161.16 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CABERGOLINE 500MCG TAB 1 TAB J8515 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CAFFEINE 200 MG TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CAFFEINE CITRATE 20 MG/ML (SDV) INJ 1 ML J0706 $99.00 636 $69.30 $49.50 $79.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CAFFEINE CITRATE 20 MG/ML ORAL LIQ SYRG 1 ML $33.60 250 $23.52 $16.80 $26.88 65% 80% 50% 50% 65% 65% 65% PHARMACY CAFFEINE-ERGOTAMINE 100/1 MG TAB 1 TAB $24.68 250 $17.28 $12.34 $19.75 65% 80% 50% 50% 65% 65% 65% PHARMACY CAFFEINE-SODIUM BENZOATE 125 MG-125 MG/ML INJ 1 ML $48.49 250 $33.94 $24.24 $38.79 65% 80% 50% 50% 65% 65% 65% PHARMACY CALAMINE TOPICAL LOT 177 ML 1 APP $6.37 250 $4.46 $3.18 $5.09 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIPOTRIENE TOPICAL 0.005% CR 60 GM 1 APP "$2,132.09 " 250 "$1,492.47 " "$1,066.05 " "$1,705.68 " 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIPOTRIENE TOPICAL 0.005% CREAM 60 GM (NF) 1 APP "$2,132.09 " 250 "$1,492.47 " "$1,066.05 " "$1,705.68 " 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCITONIN 200 INTL UNITS/INH NASAL SPR 3.8ML BTL 1 SPRAY $414.89 250 $290.42 $207.45 $331.91 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCITONIN 200 UNITS/ML INJ 2ML 2 ML J0630 "$13,150.20 " 636 "$9,205.14 " "$6,575.10 " "$10,520.16 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CALCITRIOL 0.25 MCG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCITRIOL 0.5 MCG CAP 1 CAP $6.77 250 $4.74 $3.38 $5.41 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCITRIOL 1 MCG/ML INJ 1 ML J0636 $32.82 636 $22.97 $16.41 $26.25 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CALCITRIOL 1 MCG/ML ORAL SYG 1 ML $41.77 250 $29.24 $20.88 $33.41 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM (AS CARBONATE)-VITAMIN D 600 MG/400 UNITS TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM (AS CITRATE)-VIT D 315 MG-250 INTL UNITS TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM ACETATE 667 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM CARB 1250MG/5 ML (ELEMENTAL CALCIUM 500 MG) ORAL SYG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM CARBONATE (ELEMENTAL CALCIUM 200MG) 500 MG CHEW TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM CARBONATE (ELEMENTAL CALCIUM 500 MG) TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM CARBONATE 1250 MG/5 ML SUS UD 1 ML $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CALCIUM CHLORIDE 100 MG/ML INJ 10 ML VL (FOR IVPB) 10 ML $84.92 250 $59.45 $42.46 $67.94 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM CITRATE 950 MG (200 MG ELEMENTAL CALCIUM) TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM CL 100 MG/ML INJ 10 ML SYR 10 ML $37.80 250 $26.46 $18.90 $30.24 65% 80% 50% 50% 65% 65% 65% PHARMACY CALCIUM GLUCONATE 100 MG/ML (0.465 MEQ/ML) - FOR TPN USE 1 ML J0610 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CALCIUM GLUCONATE 100 MG/ML (SDV) INJ 10ML 10 ML J0610 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CALCIUM GLUCONATE 2.5% TOPICAL GEL 150 ML 1 APP $111.56 250 $78.09 $55.78 $89.25 65% 80% 50% 50% 65% 65% 65% PHARMACY CANDIDA ALBICANS EXTRACT INJ 1 ML "$1,020.60 " 250 $714.42 $510.30 $816.48 65% 80% 50% 50% 65% 65% 65% PHARMACY CAPECITABINE 150 MG TAB 1 TAB J8520 $104.97 636 $73.48 $52.49 $83.98 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CAPECITABINE 500 MG TAB 1 TAB J8521 $320.61 636 $224.42 $160.30 $256.48 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CAPREOMYCIN 1GM INJ 10 ML VL 10 ML $918.89 250 $643.22 $459.45 $735.11 65% 80% 50% 50% 65% 65% 65% PHARMACY CAPSAICIN TOPICAL 0.025% CRE 60 GM 1 APP $34.82 250 $24.38 $17.41 $27.86 65% 80% 50% 50% 65% 65% 65% PHARMACY CAPSAICIN TOPICAL 0.075% CREAM 60G (NF) 1 APP $94.33 250 $66.03 $47.16 $75.46 65% 80% 50% 50% 65% 65% 65% PHARMACY CAPTOPRIL 1 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CAPTOPRIL 12.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CAPTOPRIL 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CAPTOPRIL 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBAMAZEPINE 100 MG CHEW TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBAMAZEPINE 100 MG ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBAMAZEPINE 100 MG/5 ML ORAL SUSP 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBAMAZEPINE 200 MG ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBAMAZEPINE 200 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBAMAZEPINE XR 200 MG UD (NF) 1 TAB $14.12 250 $9.89 $7.06 $11.30 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBAMIDE PEROX OTIC 6.5% 15ML BTL 1 GTT $10.50 250 $7.35 $5.25 $8.40 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBIDO-LEVODO 10/100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBIDO-LEVODO 25/100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBIDO-LEVODO 25/250 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBIDOPA/ENTACAPONE/LEVODOPA 25 MG-200 MG-100 MG TAB NF 1 TAB $32.12 250 $22.48 $16.06 $25.69 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBIDOPA-LEVODOPA 0.25 MG/1 MG/ML ORAL SOLN 10 ML J0610 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CARBIDOPA-LEVODOPA 0.25 MG/1 MG/ML ORAL SOLN 100 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARBOPLATIN 10 MG/ML INJ 45 ML 1 ML J9045 $130.05 636 $91.04 $65.03 $104.04 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CARBOPLATIN 10 MG/ML INJ 60 ML 1 ML J9045 $100.68 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CARBOPROST 250 MCG/ML INJ 1ML 1 ML "$1,339.76 " 250 $937.83 $669.88 "$1,071.81 " 65% 80% 50% 50% 65% 65% 65% PHARMACY CARDIOPLEGIC INJ 1000 ML BAG 1000 ML $170.66 250 $119.46 $85.33 $136.53 65% 80% 50% 50% 65% 65% 65% PHARMACY CARFILZOMIB 10 MG INJ (SDV) 1 VIAL J9047 "$1,577.80 " 636 "$1,104.46 " $788.90 "$1,262.24 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CARFILZOMIB 30 MG INJ (SDV) 1 VIAL J9047 "$2,937.27 " 636 "$2,056.09 " "$1,468.64 " "$2,349.82 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CARFILZOMIB 60 MG INJ (SDV) 1 VIAL J9047 "$5,774.55 " 636 "$4,042.18 " "$2,887.27 " "$4,619.64 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CARMUSTINE VL 100MG J9050 $100.02 636 $70.02 $50.01 $80.02 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CARTEOLOL OPHT 1% SOL 5ML BTL 1 GTT $74.48 250 $52.14 $37.24 $59.58 65% 80% 50% 50% 65% 65% 65% PHARMACY CARVEDILOL 12.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARVEDILOL 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARVEDILOL 3.125 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CARVEDILOL 6.25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CASPOFUNGIN 50 MG (SDV) INJ 10 ML J0637 $394.80 636 $276.36 $197.40 $315.84 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CASPOFUNGIN 70 MG (SDV) INJ 10 ML J0637 $415.80 636 $291.06 $207.90 $332.64 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CASTOR OIL LIQ 60 ML 30 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CEFADROXIL 1000 MG TAB - NF 1 TAB $25.00 250 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% 65% PHARMACY CEFAZOLIN 1 G / 0.9% NS 100 ML IVPB (NF) 100 ML J0690 $11.36 636 $7.95 $5.68 $9.09 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFAZOLIN 10 GM INJ VL J0690 $46.20 636 $32.34 $23.10 $36.96 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFAZOLIN 1GM / 50 ML D5W PREMIX BAG 50 ML J0690 $47.67 636 $33.37 $23.84 $38.14 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFAZOLIN 1GM INJ VL J0690 $5.74 636 $4.02 $2.87 $4.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFAZOLIN 2 G/50 ML D5W PREMIX BAG 50 ML J0690 $53.63 636 $37.54 $26.81 $42.90 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFAZOLIN 20 MG/ML (DIL 1:16.5 D5W) 1 ML J0690 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFAZOLIN 500 MG VL 1 EA J0690 $6.72 636 $4.70 $3.36 $5.38 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFEPIME 1 GM/100 ML D5W IVPB PREMADE KIT 100 ML J0692 $71.17 636 $49.82 $35.58 $56.94 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFEPIME 1GM (SDV) INJ 10 ML J0692 $711.69 636 $498.18 $355.85 $569.35 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFEPIME 2 GM/100 ML D5W IVPB PREMADE KIT 100 ML J0692 $45.99 636 $32.19 $23.00 $36.79 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFEPIME 2GM (SDV) INJ 20 ML J0692 "$1,412.46 " 636 $988.72 $706.23 "$1,129.97 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFEPIME 40 MG/ML (DIL 1:2.5 D5W) 1 ML J0692 $23.94 636 $16.76 $11.97 $19.15 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFIDEROCOL 1000 MG (SDV) INJ - NF J0699 $796.95 636 $557.87 $398.48 $637.56 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFIXIME 400 MG CAP UD 1 CAP $50.40 250 $35.28 $25.20 $40.32 65% 80% 50% 50% 65% 65% 65% PHARMACY CEFOXITIN 1 GM INJ VL 10 ML J0694 $25.20 636 $17.64 $12.60 $20.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFOXITIN 1 GM/100 ML D5W PREMADE KIT 100 ML J0694 $976.50 636 $683.55 $488.25 $781.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFOXITIN 2 GM INJ VL 20 ML J0694 $83.79 636 $58.65 $41.90 $67.03 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFOXITIN 2 GM/100 ML D5W PREMADE KIT 100 ML J0694 "$1,949.50 " 636 "$1,364.65 " $974.75 "$1,559.60 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTAROLINE 400 MG INJ - NF 20 ML J0712 $889.62 636 $622.73 $444.81 $711.69 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTAROLINE 600 MG INJ - NF 30 ML J0712 $889.62 636 $622.73 $444.81 $711.69 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTAZIDIME 1 GM INJ VL - NF 1 EA J0713 $441.00 636 $308.70 $220.50 $352.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTAZIDIME 2 GM INJ VL - NF 1 EA J0713 $435.00 636 $304.50 $217.50 $348.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTAZIDIME-AVIBACTAM 0.5 G-2 G (SDV) INJ - NF J0714 "$1,507.00 " 636 "$1,054.90 " $753.50 "$1,205.60 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTOLOZANE-TAZOBACTAM 1.5 GM INJ - NF 11.4 ML J0695 $525.92 636 $368.15 $262.96 $420.74 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTRIAXONE 1 GM (SDV) INJ VL 1 EA J0696 $67.17 636 $47.02 $33.58 $53.73 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTRIAXONE 1 GM /0.9 % NACL 100 ML IVPB 100 ML J0696 "$1,722.35 " 636 "$1,205.65 " $861.18 "$1,377.88 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTRIAXONE 2 GM / 0.9 % NACL 100 ML IVPB PREMIX 100 ML J0696 "$3,110.10 " 636 "$2,177.07 " "$1,555.05 " "$2,488.08 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTRIAXONE 2 GM INJ VL 1 EA J0696 $119.70 636 $83.79 $59.85 $95.76 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTRIAXONE 250 MG / 1% LIDOCAINE HCL 1ML INJ 1 ML J0696 $8.40 636 $5.88 $4.20 $6.72 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTRIAXONE 250 MG / STERILE WATER 1ML INJ 1 ML J0696 $8.40 636 $5.88 $4.20 $6.72 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTRIAXONE 250 MG INJ VL J0696 $31.50 636 $22.05 $15.75 $25.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFTRIAXONE 500 MG INJ J0696 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEFUROXIME 500 MG TAB - NF 1 TAB $38.87 250 $27.21 $19.43 $31.09 65% 80% 50% 50% 65% 65% 65% PHARMACY CELECOXIB 200 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CEMIPLIMAB 350 MG/7 ML INJ (SDV) - NF 7 ML J9119 "$24,972.05 " 636 "$17,480.43 " "$12,486.02 " "$19,977.64 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CEPHALEXIN 250 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CEPHALEXIN 250 MG/5 ML ORAL SYG 5 ML $5.03 250 $3.52 $2.52 $4.03 65% 80% 50% 50% 65% 65% 65% PHARMACY CEPHALEXIN 500 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CERTOLIZUMAB 200 MG/ML KIT - NF 1 ML J0717 "$20,225.35 " 636 "$14,157.74 " "$10,112.67 " "$16,180.28 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CETIRIZINE 1 MG/ML ORAL SYR - NF 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CETIRIZINE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CETUXIMAB 2 MG/ML INJ 100 ML (SDV) 100 ML J9055 "$1,997.21 " 636 "$1,398.05 " $998.61 "$1,597.77 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CETUXIMAB 2 MG/ML INJ 50 ML (SDV) 50 ML J9055 "$1,099.77 " 636 $769.84 $549.88 $879.81 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHARCOAL 25 GM SUS 120ML 120 ML $103.92 250 $72.74 $51.96 $83.13 65% 80% 50% 50% 65% 65% 65% PHARMACY CHARCOAL 50 GM SUS 8OZ 240 ML $82.77 250 $57.94 $41.39 $66.22 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORAMBUCIL 2 MG TAB 1 TAB S0172 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLORDIAZEPOXIDE 25 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORDIAZEPOXIDE 5 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORHEXIDINE ORAL 0.12% LIQ 4 OZ BOTTLE 15 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORHEXIDINE ORAL RINSE 0.12% LIQ 473 ML 15 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORHEXIDINE ORAL RINSE 0.12% UNIT DOSE 15 ML $7.98 250 $5.59 $3.99 $6.38 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORHEXIDINE TOPICAL 4% SOAP 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLOROPROCAINE 10 MG/ML INTRATHECAL INJ 1 ML J2400 $352.80 636 $246.96 $176.40 $282.24 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLOROPROCAINE 2% INJ 20 ML 20 ML J2400 $89.50 636 $62.65 $44.75 $71.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLOROPROCAINE 3% INJ 20ML VL 20 ML J2400 $94.00 636 $65.80 $47.00 $75.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLOROQUINE 500 MG TAB 1 TAB $83.49 250 $58.44 $41.74 $66.79 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLOROQUINE PHOSPHATE SYRUP 16.7 MG/ML 1 EA $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLOROTHIAZIDE SUSP 50 MG/1 ML - NF 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORPHENIRAMINE 4 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORPROMAZINE 100 MG TAB UD 1 TAB Q0161 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLORPROMAZINE 200 MG TAB UD 1 TAB Q0161 $6.43 636 $4.50 $3.22 $5.14 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLORPROMAZINE 25 MG TAB 1 TAB Q0161 $10.24 636 $7.17 $5.12 $8.19 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLORPROMAZINE 25 MG/ML INJ 1ML AMP 1 ML J3230 $121.33 636 $84.93 $60.67 $97.07 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLORPROMAZINE 50 MG INJ 2ML AMP 2 ML J3230 $139.03 636 $97.32 $69.51 $111.22 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLORPROMAZINE 50 MG TAB UD 1 TAB Q0161 $35.77 636 $25.04 $17.88 $28.61 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CHLORTHALIDONE 25 MG TAB UD 1 TAB $9.45 250 $6.62 $4.73 $7.56 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORTHALIDONE 25 MG TAB UD 1 TAB $9.45 250 $6.62 $4.73 $7.56 65% 80% 50% 50% 65% 65% 65% PHARMACY CHLORTHALIDONE 50 MG TAB 1 TAB $5.21 250 $3.65 $2.60 $4.17 65% 80% 50% 50% 65% 65% 65% PHARMACY CHOLECALCIFEROL 1000 INTL UNITS (25 MCG) TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHOLECALCIFEROL 2000 INTL UNITS (50 MCG) TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHOLECALCIFEROL 400 INTL UNITS/ML (10 MCG/ML) LIQ 1 ML $30.63 250 $21.44 $15.31 $24.50 65% 80% 50% 50% 65% 65% 65% PHARMACY CHOLECALCIFEROL 5000 INTL UNITS (125 MCG) TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHOLESTYRAMINE 4 G/5 G PWD PKT UD (NF) 1 PKT $17.90 250 $12.53 $8.95 $14.32 65% 80% 50% 50% 65% 65% 65% PHARMACY CHONDROITIN-GLUCOSAMINE 400 MG-500 MG CAP (NF) 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CHORIONIC GONADO (HCG) 10000 UNITS 10 ML J0725 $447.55 636 $313.29 $223.78 $358.04 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CICLOPIROX TOP 0.77% CRE 30GM TU 1 APP $178.85 250 $125.19 $89.42 $143.08 65% 80% 50% 50% 65% 65% 65% PHARMACY CIDOFOVIR 75 MG/ML INJ 5 ML VL 5 ML J0740 "$3,108.00 " 636 "$2,175.60 " "$1,554.00 " "$2,486.40 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CILOSTAZOL 100 MG TAB 1 TAB $7.88 250 $5.51 $3.94 $6.30 65% 80% 50% 50% 65% 65% 65% PHARMACY CINACALCET 30 MG TAB 1 TAB $108.50 250 $75.95 $54.25 $86.80 65% 80% 50% 50% 65% 65% 65% PHARMACY CINACALCET 30 MG TAB 1 TAB $108.50 250 $75.95 $54.25 $86.80 65% 80% 50% 50% 65% 65% 65% PHARMACY CINACALCET 30 MG TAB 1 TAB $108.50 250 $75.95 $54.25 $86.80 65% 80% 50% 50% 65% 65% 65% PHARMACY CINACALCET 30 MG TAB 1 TAB $108.50 250 $75.95 $54.25 $86.80 65% 80% 50% 50% 65% 65% 65% PHARMACY CINACALCET 30 MG TAB 1 TAB $108.50 250 $75.95 $54.25 $86.80 65% 80% 50% 50% 65% 65% 65% PHARMACY CINACALCET 30 MG TAB FOR ESRD 1 TAB J0604 $112.94 636 $79.06 $56.47 $90.35 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CINACALCET 60 MG TAB - NF 1 TAB $225.88 250 $158.11 $112.94 $180.70 65% 80% 50% 50% 65% 65% 65% PHARMACY CINACALCET 60 MG TAB FOR ESRD - NF 1 TAB J0604 $225.88 636 $158.11 $112.94 $180.70 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CINACALCET 90 MG TAB - NF 1 TAB $338.81 250 $237.17 $169.41 $271.05 65% 80% 50% 50% 65% 65% 65% PHARMACY CINACALCET 90 MG TAB FOR ESRD - NF 1 TAB J0604 $338.81 636 $237.17 $169.41 $271.05 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CIPROFLOXACIN 250 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CIPROFLOXACIN 500 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CIPROFLOXACIN 750 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CIPROFLOXACIN OPHT 0.3% SOL - OPHTH 1 GTT $9.56 250 $6.69 $4.78 $7.65 65% 80% 50% 50% 65% 65% 65% PHARMACY CIPROFLOXACIN OPHT 0.3% SOL 2.5ML BTL 1 GTT $44.10 250 $30.87 $22.05 $35.28 65% 80% 50% 50% 65% 65% 65% PHARMACY CIPROFLOXACIN OPHTHALMIC 0.3% SOL 5ML BTL 1 GTT $11.76 250 $8.23 $5.88 $9.41 65% 80% 50% 50% 65% 65% 65% PHARMACY CIPROFLOXACIN-DEXAMETHASONE OTIC 0.3%-0.1% SUSP - NF 1 GTT $139.49 250 $97.64 $69.75 $111.59 65% 80% 50% 50% 65% 65% 65% PHARMACY CISATRACURIUM 2 MG/ML INJ 5 ML VL 5 ML $63.09 250 $44.16 $31.54 $50.47 65% 80% 50% 50% 65% 65% 65% PHARMACY CISATRACURIUM 20 MG/10 ML INJ 10 ML $96.60 250 $67.62 $48.30 $77.28 65% 80% 50% 50% 65% 65% 65% PHARMACY CISPLATIN 1MG/1ML INJ 100 ML VL 1 ML J9060 $137.40 636 $96.18 $68.70 $109.92 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CISPLATIN 1MG/1ML INJ 50 ML VL 1 ML J9060 $121.16 636 $84.81 $60.58 $96.93 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CITALOPRAM 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CITALOPRAM 20 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CITALOPRAM 40 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CITRIC ACID/SIMETHICONE/SODIUM BICARBONATE 1.53 G-0.04 G-2.21G/4 G EFG UD 1 PKT $10.65 250 $7.46 $5.33 $8.52 65% 80% 50% 50% 65% 65% 65% PHARMACY CITRIC ACID-SODIUM CITRATE 15 ML SOL UD 15 ML $13.74 250 $9.62 $6.87 $10.99 65% 80% 50% 50% 65% 65% 65% PHARMACY CLADRIBINE 1 MG/ML (SDV) INJ - NF 10 ML J9065 $147.00 636 $102.90 $73.50 $117.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CLARITHROMYCIN 250 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLARITHROMYCIN 500 MG TAB UD 1 TAB $9.64 250 $6.75 $4.82 $7.71 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN 150 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN 150 MG/ML INJ 4 ML VL 4 ML $12.18 250 $8.53 $6.09 $9.74 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN 150 MG/ML INJ 6 ML VL 1 ML $17.64 250 $12.35 $8.82 $14.11 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN 300 MG/2ML (SDV) INJ 2 ML 2 ML $10.29 250 $7.20 $5.15 $8.23 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN 600 MG INJ 50 ML D5W PREMIX BAG 50 ML $44.86 250 $31.40 $22.43 $35.88 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN 75 MG/5 ML ORAL SYRG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN 900 MG/50 ML D5W PREMIX BAG 50 ML $54.81 250 $38.37 $27.41 $43.85 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN TOPICAL 1% SOL 60 ML 1 APP $121.10 250 $84.77 $60.55 $96.88 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN TOPICAL 1% SOLN 30ML 1 APP $103.22 250 $72.25 $51.61 $82.57 65% 80% 50% 50% 65% 65% 65% PHARMACY CLINDAMYCIN TOPICAL 1% SWAB 1 SWAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOBAZAM 10 MG TAB UD 1 TAB $9.10 250 $6.37 $4.55 $7.28 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOBAZAM 2.5 MG/ML ORAL SUSP 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOBETASOL TOPICAL 0.05% GEL 30 GM 1 APP $972.75 250 $680.93 $486.38 $778.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOBETASOL TOPICAL 0.05% OIN 15GM TU 1 APP $544.07 250 $380.85 $272.04 $435.26 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOBETASOL TOPICAL 0.05% OIN 45 GM 1 APP "$1,453.20 " 250 "$1,017.24 " $726.60 "$1,162.56 " 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOFARABINE 1 MG/ML INJ 20ML VL - NF 1 ML J9027 "$1,093.50 " 636 $765.45 $546.75 $874.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CLOMIPRAMINE 25 MG CAP 1 CAP $29.09 250 $20.36 $14.54 $23.27 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOMIPRAMINE 50 MG CAP 1 CAP $27.49 250 $19.25 $13.75 $22.00 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONAZEPAM 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONAZEPAM 100 MCG/ML ORAL SYRG (PED) 1 ML $4.15 250 $2.90 $2.07 $3.32 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONAZEPAM 2 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONAZEPAM 500 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONAZEPAM ODT 1 MG TAB - NF 1 TAB $5.19 250 $3.63 $2.59 $4.15 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONAZEPAM ODT 2 MG TAB - NF 1 TAB $7.19 250 $5.03 $3.59 $5.75 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONIDINE 100 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONIDINE 100 MCG/24 HR PATCH 1 PATCH $115.93 250 $81.15 $57.96 $92.74 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONIDINE 20 MCG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONIDINE 200 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONIDINE 200 MCG/24 HR PATCH 1 PATCH $195.18 250 $136.62 $97.59 $156.14 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONIDINE 300 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLONIDINE 300 MCG/24 HR PATCH 1 PATCH $270.76 250 $189.53 $135.38 $216.61 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOPIDOGREL 75 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOTRIMAZOLE 10 MG LOZ UD - NF 1 LOZENGE $5.00 250 $3.50 $2.50 $4.00 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOTRIMAZOLE TOP 1% SOL 10 ML BTL 1 APP $157.96 250 $110.57 $78.98 $126.36 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOTRIMAZOLE TOPICAL 1% SOL 30ML BTL 1 APP $261.56 250 $183.09 $130.78 $209.24 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOTRIMAZOLE VAG 1% CRE 45 GM TU 1 APP $28.00 250 $19.60 $14.00 $22.40 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOZAPINE 100 MG TAB UD (NF) 1 TAB $12.00 250 $8.40 $6.00 $9.60 65% 80% 50% 50% 65% 65% 65% PHARMACY CLOZAPINE 25 MG TAB UD (NF) 1 TAB S0136 $4.63 636 $3.24 $2.32 $3.70 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY COAGULATION FACTOR IX RECOMBINANT (BENEFIX) 1000 IU J7195 "$6,090.00 " 636 "$4,263.00 " "$3,045.00 " "$4,872.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY COAGULATION FACTOR IX RECOMBINANT (BENEFIX) 3000 IU 1 UNITS J7195 $6.76 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY COAGULATION FACTOR IX RECOMBINANT (BENEFIX) 3000 IU - NF J7195 "$18,270.00 " 636 "$12,789.00 " "$9,135.00 " "$14,616.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY COAL TAR 0.5% TOPICAL SHAMPOO 1 APP $20.27 250 $14.19 $10.13 $16.21 65% 80% 50% 50% 65% 65% 65% PHARMACY COAL TAR TOPICAL 20% SOL 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY COBICISTAT 150 MG TAB 1 TAB $35.47 250 $24.83 $17.73 $28.37 65% 80% 50% 50% 65% 65% 65% PHARMACY COBICISTAT-DARUNAVIR (PREZCOBIX) 150 MG-800 MG TAB 1 TAB $295.26 250 $206.68 $147.63 $236.21 65% 80% 50% 50% 65% 65% 65% PHARMACY COCAINE NASAL 4% SOL 4 ML BTL 1 APP C9046 $257.25 636 $180.08 $128.63 $205.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CODEINE SULFATE 30 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY COENZYME Q 10 100MG CAP - NF 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY COLCHICINE 600 MCG TAB UD 1 TAB $9.52 250 $6.66 $4.76 $7.61 65% 80% 50% 50% 65% 65% 65% PHARMACY COLESEVELAM 3.75 G POW $93.74 250 $65.62 $46.87 $75.00 65% 80% 50% 50% 65% 65% 65% PHARMACY COLESTIPOL 1 GM TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY COLISTIMETHATE 150 MG (SDV) INJ 2 ML J0770 $119.77 636 $83.84 $59.89 $95.82 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY COLLAGEN MICROFIB 1GM PWD $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY COLLAGENASE OINT 250 UNITS/GM 30GM TU 1 APP "$1,097.04 " 250 $767.93 $548.52 $877.63 65% 80% 50% 50% 65% 65% 65% PHARMACY COLLAGENASE TOPICAL 250 UNITS/G OINT 90 GM (NF) 1 APP "$3,127.95 " 250 "$2,189.57 " "$1,563.98 " "$2,502.36 " 65% 80% 50% 50% 65% 65% 65% PHARMACY COLON ELECTROLYTE LAVAGE SOLN 4L (GOLYTELY) 4 L $59.50 250 $41.65 $29.75 $47.60 65% 80% 50% 50% 65% 65% 65% PHARMACY CONJ ESTROGEN 0.3 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CONJUGATED ESTROGENS 25 MG INJ VL J1410 "$1,374.31 " 636 $962.02 $687.16 "$1,099.45 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CONJUGATED ESTROGENS 450 MCG TAB 1 TAB $26.04 250 $18.23 $13.02 $20.83 65% 80% 50% 50% 65% 65% 65% PHARMACY COPPER - INTRAUTERINE DEVICE (PARAGARD) 1 KIT J7300 "$2,891.00 " 636 "$2,023.70 " "$1,445.50 " "$2,312.80 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY COPPER 0.4 MG/ML (CUPRIC CHLORIDE 1.07 MG/ML) INJ - NF 1 ML $84.94 250 $59.46 $42.47 $67.95 65% 80% 50% 50% 65% 65% 65% PHARMACY CORTICORELIN 100 MCG POW 1 EA J0795 "$3,832.75 " 636 "$2,682.92 " "$1,916.37 " "$3,066.20 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY COSYNTROPIN 250MCG INJ VL 1 ML J0834 "$3,368.40 " 636 "$2,357.88 " "$1,684.20 " "$2,694.72 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CRIZANLIZUMAB TMCA 10 MG/ML SOL 1 VIAL J0791 $501.42 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CROMOLYN 10 MG/ML INH 2ML - NF 1 NEB J7631 $75.92 636 $53.14 $37.96 $60.73 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CROMOLYN OPHT 4% SOL 10ML BTL 1 GTT $130.20 250 $91.14 $65.10 $104.16 65% 80% 50% 50% 65% 65% 65% PHARMACY CYANOCOBALAMIN 100 MCG TAB UD - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CYANOCOBALAMIN 1000 MCG (VIT B12) TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CYANOCOBALAMIN 1000 MCG/ML 1ML VL 1 ML J3420 $30.59 636 $21.41 $15.30 $24.47 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOBENZAPRINE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY CYCLOBENZAPRINE 5 MG TAB UD 1 TAB $4.38 250 $3.06 $2.19 $3.50 65% 80% 50% 50% 65% 65% 65% PHARMACY CYCLOPENTOLATE OPHT 0.5% 15ML BTL 1 GTT $330.75 250 $231.53 $165.38 $264.60 65% 80% 50% 50% 65% 65% 65% PHARMACY CYCLOPENTOLATE OPHT 1% SOL - OPHTH 1 GTT $29.40 250 $20.58 $14.70 $23.52 65% 80% 50% 50% 65% 65% 65% PHARMACY CYCLOPENTOLATE OPHT 1% SOL 2ML BTL 1 GTT $58.80 250 $41.16 $29.40 $47.04 65% 80% 50% 50% 65% 65% 65% PHARMACY CYCLOPENTOLATE-PHENYLEPH OPT 2ML 1 GTT $120.96 250 $84.67 $60.48 $96.77 65% 80% 50% 50% 65% 65% 65% PHARMACY CYCLOPENTOLATE-PHENYLEPH SOL - OPHTH 1 GTT $49.56 250 $34.69 $24.78 $39.65 65% 80% 50% 50% 65% 65% 65% PHARMACY CYCLOPHOSPHAMIDE 1000 MG INJ (SDV) J9070 $414.01 636 $289.80 $207.00 $331.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOPHOSPHAMIDE 200 MG/ML INJ 10 ML VL 1 VIAL J9070 $615.30 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOPHOSPHAMIDE 25 MG CAP 1 CAP J8530 $21.00 636 $14.70 $10.50 $16.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOPHOSPHAMIDE 50 MG CAP 1 CAP J8530 $29.40 636 $20.58 $14.70 $23.52 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOSERINE 250 MG CAP 1 CAP $15.49 250 $10.84 $7.74 $12.39 65% 80% 50% 50% 65% 65% 65% PHARMACY CYCLOSPORINE 100 MG/ML ORAL SOL 1 ML J7502 $62.99 636 $44.09 $31.49 $50.39 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOSPORINE 25 MG CAP 1 CAP J7515 $12.25 636 $8.58 $6.13 $9.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOSPORINE 25 MG CAP UD - NF 1 CAP J7515 $9.46 636 $6.62 $4.73 $7.57 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOSPORINE 50 MG/ML INJ - NF 1 ML J7516 $32.85 636 $22.99 $16.42 $26.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOSPORINE MICROEMULSION 100 MG/ML LIQ 50 ML BTL 1 ML J7502 $41.22 636 $28.85 $20.61 $32.97 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYCLOSPORINE OPHTH SOLN 0.4ML UD 1 GTT $43.04 250 $30.13 $21.52 $34.43 65% 80% 50% 50% 65% 65% 65% PHARMACY CYPROHEPTADINE 4 MG NF 1 TAB $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% PHARMACY CYSTEINE 50 MG/ML INJ 1 ML $332.90 250 $233.03 $166.45 $266.32 65% 80% 50% 50% 65% 65% 65% PHARMACY CYTARABINE 100 MG/ML INJ (SDV) 20ML 20 ML J9100 $114.01 636 $79.81 $57.01 $91.21 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYTARABINE 20 MG/ML INJ (SDV) 5ML 5 ML J9100 $108.97 636 $76.28 $54.48 $87.17 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYTARABINE 20 MG/ML SOL 50 ML VL 1 ML J9100 $147.77 636 $103.44 $73.89 $118.22 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY CYTARABINE LIPOSOMAL 10 MG/ML INJ 1 ML J9098 "$3,535.67 " 636 "$2,474.97 " "$1,767.84 " "$2,828.54 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DABIGATRAN 150 MG CAP 1 CAP $27.53 250 $19.27 $13.76 $22.02 65% 80% 50% 50% 65% 65% 65% PHARMACY DABIGATRAN 75 MG CAP 1 CAP $27.53 250 $19.27 $13.76 $22.02 65% 80% 50% 50% 65% 65% 65% PHARMACY DACARBAZINE 200 MG (SDV) INJ J9130 $206.90 636 $144.83 $103.45 $165.52 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DACTINOMYCIN 500 MCG (SDV) INJ 1 ML J9120 "$1,341.39 " 636 $938.98 $670.70 "$1,073.12 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DALBAVANCIN 500 MG INJ (SDV) - NF J0875 "$6,838.27 " 636 "$4,786.79 " "$3,419.13 " "$5,470.61 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DALFOPRISTIN-QUINUPRISTIN 350 MG-150 MG (SDV) INJ - NF J2770 "$1,957.24 " 636 "$1,370.07 " $978.62 "$1,565.79 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DANAZOL 200 MG CAP 1 CAP $5.04 250 $3.53 $2.52 $4.03 65% 80% 50% 50% 65% 65% 65% PHARMACY DANAZOL 200 MG CAP UD (NF) 1 CAP $16.88 250 $11.81 $8.44 $13.50 65% 80% 50% 50% 65% 65% 65% PHARMACY DANTROLENE 20 MG INJ VL "$1,764.00 " 250 "$1,234.80 " $882.00 "$1,411.20 " 65% 80% 50% 50% 65% 65% 65% PHARMACY DANTROLENE 25 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DANTROLENE 250 MG INJ "$11,844.14 " 250 "$8,290.90 " "$5,922.07 " "$9,475.31 " 65% 80% 50% 50% 65% 65% 65% PHARMACY DANTROLENE 5 MG/ML ORAL SYRG (PED) 1 ML $4.14 250 $2.90 $2.07 $3.31 65% 80% 50% 50% 65% 65% 65% PHARMACY DAPSONE 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DAPSONE 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DAPTOMYCIN 500 MG (SDV) INJ 10 ML J0878 "$1,871.03 " 636 "$1,309.72 " $935.52 "$1,496.82 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DARATUMUMAB 100 MG/ 5ML (SDV) INJ 5 ML J9145 $444.96 636 $311.48 $222.48 $355.97 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DARATUMUMAB 400 MG/20 ML (SDV) INJ 20 ML J9145 $444.96 636 $311.48 $222.48 $355.97 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DARBEPOETIN ALFA 100 MCG/ML INJ (SDV) FOR ESRD 1 ML J0882 "$3,250.80 " 636 "$2,275.56 " "$1,625.40 " "$2,600.64 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DARBEPOETIN ALFA 100 MCG/ML INJ (SDV) FOR ONCOLOGY 1 ML J0881 "$3,250.80 " 636 "$2,275.56 " "$1,625.40 " "$2,600.64 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DARBEPOETIN ALFA 25 MCG/ML INJ (SDV) FOR ESRD 1 ML J0882 $812.70 636 $568.89 $406.35 $650.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DARBEPOETIN ALFA 40 MCG/ML (SDV) INJ FOR ESRD 1 ML J0882 "$1,300.32 " 636 $910.22 $650.16 "$1,040.26 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DARBEPOETIN ALFA 60 MCG/ML (SDV) INJ FOR ESRD 1 ML J0882 "$1,950.48 " 636 "$1,365.34 " $975.24 "$1,560.38 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DARUNAVIR 600 MG TAB 1 TAB $33.50 250 $23.45 $16.75 $26.80 65% 80% 50% 50% 65% 65% 65% PHARMACY DARUNAVIR 800 MG TAB 1 TAB $258.33 250 $180.83 $129.16 $206.66 65% 80% 50% 50% 65% 65% 65% PHARMACY DASATINIB 100 MG TAB - NF 1 TAB "$2,122.52 " 250 "$1,485.76 " "$1,061.26 " "$1,698.02 " 65% 80% 50% 50% 65% 65% 65% PHARMACY DASATINIB 140 MG TAB 1 TAB "$2,122.52 " 250 "$1,485.76 " "$1,061.26 " "$1,698.02 " 65% 80% 50% 50% 65% 65% 65% PHARMACY DASATINIB 70 MG TAB - NF 1 TAB "$1,177.65 " 250 $824.36 $588.83 $942.12 65% 80% 50% 50% 65% 65% 65% PHARMACY DAUNORUBICIN 5 MG/ML (SDV) INJ 4 ML 4 ML J9150 $213.49 636 $149.44 $106.75 $170.79 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DAUNORUBICIN LIPOSOMAL - CYTARABINE LIPOSOMAL 44 MG-100 MG (SDV) INJ J9153 "$37,346.69 " 636 "$26,142.69 " "$18,673.35 " "$29,877.36 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DECITABINE 50 MG (SDV) INJ - NF J0894 $244.30 636 $171.01 $122.15 $195.44 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEFEROXAMINE 500 MG INJ VL 2 ML J0895 $54.39 636 $38.07 $27.20 $43.51 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEGARELIX 240 MG KIT 1 KIT J9155 "$3,200.79 " 636 "$2,240.55 " "$1,600.39 " "$2,560.63 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEGARELIX 80 MG KIT - NF 1 KIT J9155 "$2,051.49 " 636 "$1,436.04 " "$1,025.75 " "$1,641.19 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEMECLOCYCLINE 150 MG TAB 1 TAB $7.34 250 $5.14 $3.67 $5.87 65% 80% 50% 50% 65% 65% 65% PHARMACY DENOSUMAB 120 MG/1.7 ML (SDV) INJ - NF 1.7 ML J0897 "$6,154.34 " 636 "$4,308.04 " "$3,077.17 " "$4,923.47 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DENOSUMAB 60 MG/ML (PROLIA) INJ 1 ML J0897 "$5,687.82 " 636 "$3,981.47 " "$2,843.91 " "$4,550.25 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DESFLURANE 100% LIQ 240ML BTL 240 ML $672.92 250 $471.05 $336.46 $538.34 65% 80% 50% 50% 65% 65% 65% PHARMACY DESIPRAMINE 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DESIPRAMINE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DESMOPRESSIN 0.5 MCG/ML (DIL 1:8 NS) 1 ML J2597 $30.87 636 $21.61 $15.43 $24.69 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DESMOPRESSIN 10 MCG/INH RHINAL TUBE SPRAY 5 ML 1 SPRAY $172.38 250 $120.66 $86.19 $137.90 65% 80% 50% 50% 65% 65% 65% PHARMACY DESMOPRESSIN 100 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DESMOPRESSIN 200 MCG TAB 1 TAB $26.65 250 $18.66 $13.33 $21.32 65% 80% 50% 50% 65% 65% 65% PHARMACY DESMOPRESSIN 4 MCG/ML INJ 1 ML VL 1 ML J2597 $246.93 636 $172.85 $123.47 $197.55 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DESMOPRESSIN 4 MCG/ML INJ 10 ML VL 1 ML J2597 "$2,496.34 " 636 "$1,747.44 " "$1,248.17 " "$1,997.07 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE 0.75 MG TAB - NF 1 TAB $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXAMETHASONE 10 MG/ML (SDV) 1 ML 1 ML J1100 $26.29 636 $18.40 $13.15 $21.03 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE 10 MG/ML PF (SDV) INJ 1 ML J1100 $26.29 636 $18.40 $13.15 $21.03 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE 2 MG TAB UD 1 TAB J8540 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE 4 MG TAB UD 1 TAB J8540 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE 4 MG/ML (SDV) 1 ML 1 ML J1100 $11.05 636 $7.73 $5.52 $8.84 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE 4 MG/ML INJ (SDV) 1ML 1 ML J1100 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE 4 MG/ML INJ 5ML VL 5 ML J1100 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE 500 MCG TAB UD 1 TAB J8540 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE 500 MCG/5 ML ORAL SYRG 5 ML J8540 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE OPHT 0.1% 5ML BTL 1 GTT $226.38 250 $158.47 $113.19 $181.10 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXAMETHASONE OPHTHALMIC 0.4 MG (DEXTENZA) INSERT 1 EA J1096 "$2,170.95" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE OPHTHALMIC 0.7 MG IMPLANT J7312 "$4,532.50 " 636 "$3,172.75 " "$2,266.25 " "$3,626.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXAMETHASONE OPTH 0.1% OPHTH 1 GTT $47.17 250 $33.02 $23.58 $37.73 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMEDETOMIDINE 100 MCG/ML INJ 2 ML 1 ML $80.18 250 $56.12 $40.09 $64.14 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMETHYLPHENIDATE 10 MG ER CAP - NF 1 CAP $54.06 250 $37.84 $27.03 $43.25 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMETHYLPHENIDATE 10 MG TAB 1 TAB $4.90 250 $3.43 $2.45 $3.92 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMETHYLPHENIDATE 15 MG ER CAP - NF 1 CAP $55.60 250 $38.92 $27.80 $44.48 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMETHYLPHENIDATE 2.5 MG TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMETHYLPHENIDATE 20 MG ER CAP - NF 1 CAP $55.60 250 $38.92 $27.80 $44.48 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMETHYLPHENIDATE 25 MG ER CAP - NF 1 CAP $58.38 250 $40.86 $29.19 $46.70 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMETHYLPHENIDATE 30 MG ER CAP 1 CAP $24.95 250 $17.47 $12.48 $19.96 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMETHYLPHENIDATE 5 MG ER CAP - NF 1 CAP $53.27 250 $37.29 $26.64 $42.62 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXMETHYLPHENIDATE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXRAZOXANE 250 MG (ZINECARD) (SDV) INJ - NF J1190 $353.70 636 $247.59 $176.85 $282.96 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXRAZOXANE 500 MG (ZINECARD) (SDV) INJ - NF J1190 "$1,925.74 " 636 "$1,348.01 " $962.87 "$1,540.59 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXTROAMPHETAMINE 10 MG TAB (NF) 1 TAB S0160 $11.03 636 $7.72 $5.51 $8.82 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXTROMETHORPHAN 10 MG/5 ML ORAL LIQ 1 EA $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DEXTROMETHORPHAN 15 MG/5 ML ORAL SYRG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXTROSE 10% 0.9% SOD CHLORIDE 250 ML 250 ML $15.00 250 $10.50 $7.50 $12.00 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXTROSE 25% PEDS (GLUCOSE 12.5 G) 10 ML SYR 10 ML $40.34 250 $28.24 $20.17 $32.27 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXTROSE 50% (GLUCOSE 25 G) INJ 50 ML SYG 50 ML $38.65 250 $27.05 $19.32 $30.92 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXTROSE 50% (GLUCOSE 25 G) INJ 50 ML VL 50 ML $13.04 250 $9.13 $6.52 $10.43 65% 80% 50% 50% 65% 65% 65% PHARMACY DEXTROSE 70% IN WATER 2000 ML 2000 ML $279.59 250 $195.71 $139.80 $223.67 65% 80% 50% 50% 65% 65% 65% PHARMACY DIAZEPAM 1 MG/1 ML ORAL SOL 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIAZEPAM 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIAZEPAM 2 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIAZEPAM 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIAZEPAM 5 MG/ML INJ 2ML SYG 2 ML J3360 $115.68 636 $80.98 $57.84 $92.55 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIAZOXIDE 50 MG/ML ORAL SYG - NF 1 ML $43.35 250 $30.34 $21.67 $34.68 65% 80% 50% 50% 65% 65% 65% PHARMACY DIBUCAINE TOP 1% OIN 30GM TU 1 APP $20.62 250 $14.43 $10.31 $16.49 65% 80% 50% 50% 65% 65% 65% PHARMACY DICLOFENAC OPHTHALMIC 0.1% SOL 1 GTT $61.25 250 $42.88 $30.63 $49.00 65% 80% 50% 50% 65% 65% 65% PHARMACY DICLOFENAC SODIUM 50 MG DR TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DICLOFENAC SODIUM 75 MG DR TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DICLOFENAC SODIUM 75 MG TAB UD NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DICLOFENAC TOPICAL 1% GEL - NF 1 APP $181.72 250 $127.20 $90.86 $145.38 65% 80% 50% 50% 65% 65% 65% PHARMACY DICLOXACILLIN 250 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DICLOXACILLIN 500 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DICYCLOMINE 10 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DICYCLOMINE 20 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIFLUPREDNATE OPHTHALMIC 0.05% EMU - NF 1 GTT $174.40 250 $122.08 $87.20 $139.52 65% 80% 50% 50% 65% 65% 65% PHARMACY DIGOXIN 100 MCG/ML INJ 1ML AMP PED 1 ML J1160 $482.90 636 $338.03 $241.45 $386.32 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIGOXIN 125 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIGOXIN 20 MCG/ML (DIL 1:5 D5W) 1 ML $84.39 250 $59.07 $42.19 $67.51 65% 80% 50% 50% 65% 65% 65% PHARMACY DIGOXIN 250 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIGOXIN 250 MCG/ML INJ 2ML AMP 1 ML J1160 $23.10 636 $16.17 $11.55 $18.48 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIGOXIN 50 MCG/ML (0.05 MG/ML) ELIX ORAL SYG 1 ML $9.80 250 $6.86 $4.90 $7.84 65% 80% 50% 50% 65% 65% 65% PHARMACY DIGOXIN IMMUNE FAB 40 MG PWD 4 ML J1162 "$17,358.60 " 636 "$12,151.02 " "$8,679.30 " "$13,886.88 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIHYDROERGOTAM 1 MG/ML INJ 1ML AMP 1 ML J1110 $551.67 636 $386.17 $275.84 $441.34 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DILTIAZEM 120 MG/24 HOURS CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DILTIAZEM 120 MG/24 HOURS ER TAB 1 TAB $15.98 250 $11.18 $7.99 $12.78 65% 80% 50% 50% 65% 65% 65% PHARMACY DILTIAZEM 180 MG/24 HOURS CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DILTIAZEM 180 MG/24 HOURS ER TAB 1 TAB $10.41 250 $7.29 $5.21 $8.33 65% 80% 50% 50% 65% 65% 65% PHARMACY DILTIAZEM 240 MG/24 HOURS CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DILTIAZEM 240 MG/24 HOURS ER TAB 1 TAB $11.67 250 $8.17 $5.84 $9.34 65% 80% 50% 50% 65% 65% 65% PHARMACY DILTIAZEM 30 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DILTIAZEM 5 MG/ML 10 ML VIAL 10 ML $23.81 250 $16.66 $11.90 $19.05 65% 80% 50% 50% 65% 65% 65% PHARMACY DILTIAZEM 60 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DILTIAZEM 90 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIMERCAPROL 100MG/ML INJ 3ML AMP 1 ML J0470 $673.85 636 $471.69 $336.92 $539.08 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIMETHYL FUMARATE 240 MG DELAYED RELEASE CAP - NF 1 CAP $266.88 250 $186.81 $133.44 $213.50 65% 80% 50% 50% 65% 65% 65% PHARMACY DIMETHYL SULFOXIDE 50% SOL 50 ML J1212 "$2,598.09 " 636 "$1,818.66 " "$1,299.04 " "$2,078.47 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIPHENHYDRAMINE 12.5 MG/5 ML LIQ 473 ML (NF) 5 ML Q0163 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIPHENHYDRAMINE 12.5 MG/5 ML LIQ UD 5 ML Q0163 $12.54 636 $8.78 $6.27 $10.03 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIPHENHYDRAMINE 12.5MG/5ML ORAL SYG 5 ML Q0163 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIPHENHYDRAMINE 25 MG CAP UD 1 CAP Q0163 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIPHENHYDRAMINE 50 MG CAP UD 1 CAP Q0163 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIPHENHYDRAMINE 50 MG/ML INJ 1ML VL 1 ML J1200 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIPHENOX+ATROPINE 2.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIPYRIDAMOLE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIPYRIDAMOLE 5 MG/ML INJ 10 ML VL 1 ML J1245 $83.16 636 $58.21 $41.58 $66.53 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DIPYRIDAMOLE 50 MG TAB UD 1 EA $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DISOPYRAMIDE 10 MG/ML ORAL SYRG (PED) 1 ML $4.86 250 $3.40 $2.43 $3.89 65% 80% 50% 50% 65% 65% 65% PHARMACY DISOPYRAMIDE 100 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DISOPYRAMIDE 150 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIVALPROEX SODIUM 250 MG DR TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIVALPROEX SODIUM 250 MG/24 HOURS ER TAB 1 TAB $100.65 250 $70.45 $50.32 $80.52 65% 80% 50% 50% 65% 65% 65% PHARMACY DIVALPROEX SODIUM 500 MG DR TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIVALPROEX SODIUM 500 MG/24 HOURS ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DIVALPROEX SODIUM SPRINKLE 125 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DNU ATRACURIUM INJ 1000 MG/ML 100 ML VL $52.92 250 $37.04 $26.46 $42.34 65% 80% 50% 50% 65% 65% 65% PHARMACY DNU CISATRACURIUM 2 MG/ML INJ 10 ML PREMIX $96.60 250 $67.62 $48.30 $77.28 65% 80% 50% 50% 65% 65% 65% PHARMACY DNU DEXMEDETOMIDINE/0.9% NS 200 MCG/50ML (PREMIX) $180.60 250 $126.42 $90.30 $144.48 65% 80% 50% 50% 65% 65% 65% PHARMACY DNU DEXMEDETOMIDINE/0.9% NS 400 MCG/100ML (PREMIX) $336.00 250 $235.20 $168.00 $268.80 65% 80% 50% 50% 65% 65% 65% PHARMACY DNU DOBUTAMINE 1000 MG/250 ML D5W PREMIX BAG J1250 $112.61 636 $78.83 $56.31 $90.09 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU DOBUTAMINE 250 MG/250 ML D5W PREMIX BAG J1250 $101.50 636 $71.05 $50.75 $81.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU DOBUTAMINE 500 MG/250 ML D5W PREMIX BAG J1250 $171.80 636 $120.26 $85.90 $137.44 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU DOPAMINE 800 MG D5W 250 ML PREMIX BAG J1265 $76.25 636 $53.37 $38.12 $61.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU ESMOLOL 2000 MG/100 ML PREMIX BAG "$2,116.41 " 250 "$1,481.49 " "$1,058.20 " "$1,693.13 " 65% 80% 50% 50% 65% 65% 65% PHARMACY DNU FENTANYL 1000 MCG/100 ML D5W PREMADE BAG J3010 $109.69 636 $76.78 $54.85 $87.75 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "DNU HEPARIN 25,000 UNITS/250 ML PREMIX D5W" J1644 $59.05 636 $41.34 $29.53 $47.24 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU LIDOCAINE 2 GM D5W 250 ML PREMIX BAG 250 ML J2001 $48.32 636 $33.82 $24.16 $38.66 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU MAGNESIUM SULFATE 20 G/500ML STERILE WATER PREMIX J3475 $23.52 636 $16.46 $11.76 $18.82 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU MIDAZOLAM 100 MG/100 ML NS PREMADE BAG J2250 $57.96 636 $40.57 $28.98 $46.37 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU MILRINONE 20 MG D5W 100 ML PREMIX BAG J2260 $144.81 636 $101.37 $72.40 $115.85 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU MORPHINE 30 MG/30 ML PREMIX - FOR DRIP J2270 $50.40 636 $35.28 $25.20 $40.32 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU NICARDIPINE 40 MG/NACL 0.83% 200 ML INJ PREMIX $853.86 250 $597.70 $426.93 $683.09 65% 80% 50% 50% 65% 65% 65% PHARMACY DNU NITROGLYCERIN D5W 100 MG/250 ML PREMIX $94.75 250 $66.33 $47.38 $75.80 65% 80% 50% 50% 65% 65% 65% PHARMACY DNU PENTOBARBITAL 50 MG/ML INJ 50 ML VL J2515 "$9,479.40 " 636 "$6,635.58 " "$4,739.70 " "$7,583.52 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU PROPOFOL 10 MG/ML INJ 100ML VL J2704 $89.80 636 $62.86 $44.90 $71.84 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU PROPOFOL 10 MG/ML INJ 50ML VL J2704 $44.90 636 $31.43 $22.45 $35.92 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DNU ROCURONIUM 10 MG/ML INJ 10 ML VL $29.51 250 $20.66 $14.76 $23.61 65% 80% 50% 50% 65% 65% 65% PHARMACY DOBUTAMINE 250 MG INJ 20ML VL 20 ML J1250 $23.37 636 $16.36 $11.69 $18.70 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOBUTAMINE 50 MG/50 ML D5W PREMIX 50 ML J1250 $18.86 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOCETAXEL 20 MG/ML INJ 1ML VL 1 ML J9171 $106.71 636 $74.70 $53.36 $85.37 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOCETAXEL 20 MG/ML INJ 4ML VL 4 ML J9171 $126.86 636 $88.80 $63.43 $101.49 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOCUSATE 100 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOCUSATE 100 MG/10 ML LIQ 10ML 10 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOCUSATE-SENNA 50 MG-8.6 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOFETILIDE 125 MCG CAP UD 1 CAP $43.87 250 $30.71 $21.93 $35.10 65% 80% 50% 50% 65% 65% 65% PHARMACY DOFETILIDE 250 MCG CAP UD 1 CAP $43.87 250 $30.71 $21.93 $35.10 65% 80% 50% 50% 65% 65% 65% PHARMACY DOFETILIDE 500 MCG CAP UD 1 CAP $43.87 250 $30.71 $21.93 $35.10 65% 80% 50% 50% 65% 65% 65% PHARMACY DOLUTEGRAVIR 50 MG TAB 1 TAB $268.34 250 $187.84 $134.17 $214.67 65% 80% 50% 50% 65% 65% 65% PHARMACY DONEPEZIL 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DONEPEZIL 5 MG TAB (NF) 1 TAB $70.85 250 $49.60 $35.43 $56.68 65% 80% 50% 50% 65% 65% 65% PHARMACY DONEPEZIL 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOPAMINE 40 MG/ML INJ 5 ML VL 5 ML J1265 $12.29 636 $8.60 $6.14 $9.83 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DORAVIRINE 100 MG TAB - NF 1 TAB $202.86 250 $142.00 $101.43 $162.29 65% 80% 50% 50% 65% 65% 65% PHARMACY DORNASE ALFA 2.5 MG/2.5 ML UD INH SOL 2.5 ML J7639 $482.66 636 $337.86 $241.33 $386.13 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DORZOLAMIDE OPHT 2% SOL 10ML BTL 1 GTT $233.80 250 $163.66 $116.90 $187.04 65% 80% 50% 50% 65% 65% 65% PHARMACY DORZOLAMIDE-TIMOLOL OPHTHALMIC 2%-0.5% SOL 10 ML $429.10 250 $300.37 $214.55 $343.28 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXAPRAM 400MG INJ 20ML VL 1 ML $223.50 250 $156.45 $111.75 $178.80 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXAZOSIN 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXAZOSIN 2 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXAZOSIN 4 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXAZOSIN 8 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXEPIN 10 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXEPIN 10 MG/ML CONC (NF) 1 ML $124.43 250 $87.10 $62.21 $99.54 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXEPIN 25 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXEPIN 50 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXERCALCIFEROL 2 MCG/ML INJ - NF 1 ML J1270 $14.61 636 $10.23 $7.30 $11.69 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOXORUBICIN 10 MG INJ (CHEMOEMBOLIZATION) J9000 $204.82 636 $143.37 $102.41 $163.86 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOXORUBICIN 2 MG/ML (SDV) INJ 100 ML 1 ML J9000 $160.48 636 $112.33 $80.24 $128.38 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOXORUBICIN 2 MG/ML (SDV) INJ 25 ML 1 VIAL J9000 $103.70 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOXORUBICIN 50 MG (SDV) INJ (CHEMOEMBOLIZATION) J9000 "$1,104.74 " 636 $773.32 $552.37 $883.79 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOXORUBICIN LIPOSOMAL 2 MG/ML 25ML VL 1 ML Q2050 "$1,121.15 " 636 $784.81 $560.58 $896.92 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOXORUBICIN LIPOSOMAL 2 MG/ML INJ (SDV) 10 ML 10 ML Q2050 $440.38 636 $308.27 $220.19 $352.31 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DOXYCYCLINE 1 MG/ML (DIL 1:10 D5W) 1 ML $101.47 250 $71.03 $50.74 $81.18 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXYCYCLINE 100 MG CAP UD 1 CAP $4.39 250 $3.07 $2.19 $3.51 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXYCYCLINE 100 MG/100 ML D5W IVPB PREMADE KIT 100 ML $68.42 250 $47.89 $34.21 $54.73 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXYCYCLINE 100MG INJ VL 10 ML $684.18 250 $478.93 $342.09 $547.34 65% 80% 50% 50% 65% 65% 65% PHARMACY DOXYCYCLINE MONOHYDRATE 100 MG CAP NF 1 CAP $8.29 250 $5.80 $4.15 $6.63 65% 80% 50% 50% 65% 65% 65% PHARMACY DRONABINOL 2.5 MG CAP 1 CAP Q0167 $10.84 636 $7.59 $5.42 $8.67 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DROPERIDOL 2.5 MG/ML INJ 2 ML AMP 2 ML J1790 $34.44 636 $24.11 $17.22 $27.55 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DTAP/HEPB-IPV (PEDIARIX) VACCINE INJ 0.5 ML 0.5 ML $346.68 250 $242.67 $173.34 $277.34 65% 80% 50% 50% 65% 65% 65% PHARMACY DTAP/IPV (KINRIX) VACCINE INJ 0.5 ML 0.5 ML $446.16 250 $312.31 $223.08 $356.93 65% 80% 50% 50% 65% 65% 65% PHARMACY DTAP/IPV (QUADRACEL) INJ 0.5ML 0.5 ML $233.86 250 $163.70 $116.93 $187.09 65% 80% 50% 50% 65% 65% 65% PHARMACY DTAP/IPV/HIB (PENTACEL) VACCINE INJ 0.5 ML 0.5 ML $216.41 250 $151.49 $108.21 $173.13 65% 80% 50% 50% 65% 65% 65% PHARMACY DTAP-IPV-HIB-HEPB (VAXELIS) VACCINE 0.5 ML 1 EA "$1,225.06" 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DTAP-PED (DAPTACEL) VACCINE INJ 0.5 ML 0.5 ML $273.00 250 $191.10 $136.50 $218.40 65% 80% 50% 50% 65% 65% 65% PHARMACY DTAP-PED (INFANRIX) VACCINE INJ 0.5 ML 0.5 ML $210.08 250 $147.05 $105.04 $168.06 65% 80% 50% 50% 65% 65% 65% PHARMACY DT-PED (TETANUS/DIPHTH) VACCINE INJ 0.5 ML 0.5 ML $251.10 250 $175.77 $125.55 $200.88 65% 80% 50% 50% 65% 65% 65% PHARMACY DULOXETINE 20 MG DR CAP UD 1 CAP $28.58 250 $20.00 $14.29 $22.86 65% 80% 50% 50% 65% 65% 65% PHARMACY DULOXETINE 30 MG DR CAP UD 1 CAP $26.95 250 $18.87 $13.48 $21.56 65% 80% 50% 50% 65% 65% 65% PHARMACY DULOXETINE 60 MG DR CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY DUPILUMAB 300MG (DUPIXENT) INJ PFS 2 ML "$6,727.12 " 250 "$4,708.99 " "$3,363.56 " "$5,381.70 " 65% 80% 50% 50% 65% 65% 65% PHARMACY DURVALUMAB 50 MG/ML INJ 10 ML (SDV) 10 ML J9173 "$1,562.39 " 636 "$1,093.67 " $781.20 "$1,249.91 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DURVALUMAB 50 MG/ML INJ 2.4 ML (SDV) 2.4 ML J9173 "$1,562.40 " 636 "$1,093.68 " $781.20 "$1,249.92 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY DUTASTERIDE 0.5 MG CAP UD (NF) 1 CAP $33.23 250 $23.26 $16.62 $26.58 65% 80% 50% 50% 65% 65% 65% PHARMACY ECULIZUMAB (SOLIRIS) 10 MG/ML INJ 30 ML J1300 $796.88 636 $557.82 $398.44 $637.50 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EDETATE CALCIUM DISODIUM 200 MG/ML 5 ML AMP 5 ML J0600 "$20,943.48 " 636 "$14,660.44 " "$10,471.74 " "$16,754.79 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EDROPHONIUM 10 MG/ML INJ 15 ML AMP 15 ML $336.00 250 $235.20 $168.00 $268.80 65% 80% 50% 50% 65% 65% 65% PHARMACY EFAVIRENZ 600 MG TAB 1 TAB $4.53 250 $3.17 $2.27 $3.63 65% 80% 50% 50% 65% 65% 65% PHARMACY EFGARTIGIMOD ALFA 400 MG/20 ML (SDV) 1 VIAL J9332 $603.15 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ELBASVIR-GRAZOPREVIR 50 MG-100 MG TAB 1 TAB "$1,092.00 " 250 $764.40 $546.00 $873.60 65% 80% 50% 50% 65% 65% 65% PHARMACY ELOTUZUMAB 300 MG INJ (SDV) 1 EA J9176 "$3,483.89" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ELOTUZUMAB 400 MG INJ (SDV) 1 EA J9176 "$4,605.67" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ELTROMBOPAG 25 MG TAB (NF) 1 TAB $789.64 250 $552.75 $394.82 $631.71 65% 80% 50% 50% 65% 65% 65% PHARMACY ELUXADOLINE 100 MG TAB 1 TAB $96.83 250 $67.78 $48.41 $77.46 65% 80% 50% 50% 65% 65% 65% PHARMACY "EMOLLIENTS, TOPICAL - CREAM 120GM - NF" 1 APP $13.52 250 $9.46 $6.76 $10.81 65% 80% 50% 50% 65% 65% 65% PHARMACY EMPAGLIFLOZIN 10 MG TAB - NF 1 TAB $73.14 250 $51.20 $36.57 $58.51 65% 80% 50% 50% 65% 65% 65% PHARMACY EMPAGLIFLOZIN 25 MG TAB - NF 1 TAB $76.80 250 $53.76 $38.40 $61.44 65% 80% 50% 50% 65% 65% 65% PHARMACY EMTRICITABINE 200MG CAP 1 CAP $28.09 250 $19.67 $14.05 $22.48 65% 80% 50% 50% 65% 65% 65% PHARMACY EMTRICITABINE-TENOFOVIR (TRUVADA) 200/300 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY EMTRIC-RILPIV-TENO ALAF(ODEFSEY) 200 MG-25 MG-25 MG TAB 1 TAB $432.40 250 $302.68 $216.20 $345.92 65% 80% 50% 50% 65% 65% 65% PHARMACY ENALAPRIL 1 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ENALAPRIL 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ENALAPRIL 2.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ENALAPRIL 20 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ENALAPRIL 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ENALAPRILAT 1.25 MG/ML INJ VL 2 ML $36.24 250 $25.37 $18.12 $28.99 65% 80% 50% 50% 65% 65% 65% PHARMACY ENFORTUMAB VEDOTIN 20 MG (SDV) INJ J9177 "$9,933.00 " 636 "$6,953.10 " "$4,966.50 " "$7,946.40 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENFORTUMAB VEDOTIN 30 MG (SDV) INJ J9177 "$14,899.50 " 636 "$10,429.65 " "$7,449.75 " "$11,919.60 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENFUVIRTIDE 90 MG POW - NF J1324 $250.99 636 $175.69 $125.49 $200.79 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENOXAPARIN 100MG INJ 1ML SYG 1 ML J1650 $63.00 636 $44.10 $31.50 $50.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENOXAPARIN 120 MG/0.8 ML SYR 0.8 ML J1650 $75.60 636 $52.92 $37.80 $60.48 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENOXAPARIN 150 MG INJ 1ML SYG 1 ML J1650 $125.20 636 $87.64 $62.60 $100.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENOXAPARIN 20MG /1 ML INJ (DIL 0.3:1.2 SWFI) 1 ML J1650 $25.07 636 $17.55 $12.54 $20.06 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENOXAPARIN 30MG INJ 0.3ML SYG 0.3 ML J1650 $25.07 636 $17.55 $12.54 $20.06 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENOXAPARIN 40 MG/0.4 ML SYG 0.4 ML J1650 $25.20 636 $17.64 $12.60 $20.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENOXAPARIN 60MG INJ 0.6ML SYG 0.6 ML J1650 $50.11 636 $35.07 $25.05 $40.08 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENOXAPARIN 80 MG/0.8 ML SYR 0.8 ML J1650 $50.40 636 $35.28 $25.20 $40.32 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ENTACAPONE 200 MG TAB - NF 1 TAB $32.39 250 $22.67 $16.19 $25.91 65% 80% 50% 50% 65% 65% 65% PHARMACY ENTECAVIR 0.5 MG TAB 1 TAB $155.52 250 $108.87 $77.76 $124.42 65% 80% 50% 50% 65% 65% 65% PHARMACY ENTECAVIR 1 MG TAB 1 TAB $155.51 250 $108.86 $77.76 $124.41 65% 80% 50% 50% 65% 65% 65% PHARMACY ENZALUTAMIDE 80 MG TAB - NF 1 TAB $716.08 250 $501.26 $358.04 $572.87 65% 80% 50% 50% 65% 65% 65% PHARMACY EPHEDRINE 50 MG/ML INJ 1 ML $121.97 250 $85.38 $60.98 $97.57 65% 80% 50% 50% 65% 65% 65% PHARMACY EPINEPHRINE 0.15 MG KIT - NF J0171 "$1,278.08 " 636 $894.65 $639.04 "$1,022.46 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EPINEPHRINE 0.3 MG KIT NF 0.3 ML J0171 $864.52 636 $605.16 $432.26 $691.61 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EPINEPHRINE 1 MG INJ 10ML SYG 10 ML J0171 $22.00 636 $15.40 $11.00 $17.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EPINEPHRINE 1 MG/ML INJ 30ML VL 1 ML J0171 $945.00 636 $661.50 $472.50 $756.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EPINEPHRINE 1000 MCG/ML 1ML 1 ML J0171 $62.83 636 $43.98 $31.42 $50.27 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EPINEPHRINE-LIDOCAINE 1:100000-1% INJ 20 ML 20 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY EPINEPHRINE-LIDOCAINE 1:100000-1% INJ 50 ML 50 ML $15.02 250 $10.51 $7.51 $12.01 65% 80% 50% 50% 65% 65% 65% PHARMACY EPINEPHRINE-LIDOCAINE 1:100000-2% DENT CART 1 EA $20.00 250 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% PHARMACY EPINEPHRINE-LIDOCAINE 1:100000-2% INJ 20 ML VL 20 ML $15.96 250 $11.17 $7.98 $12.77 65% 80% 50% 50% 65% 65% 65% PHARMACY "EPINEPHRINE-LIDOCAINE 1:200,000-2% PF INJ 20ML VL" 20 ML $18.98 250 $13.29 $9.49 $15.19 65% 80% 50% 50% 65% 65% 65% PHARMACY EPIRUBICIN 2 MG/ML (SDV) INJ 100ML 1 ML J9178 $428.00 636 $299.60 $214.00 $342.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EPIRUBICIN 2MG/ML (SDV) INJ 25ML VL 1 ML J9178 $133.70 636 $93.59 $66.85 $106.96 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EPLERENONE 25 MG TAB - NF 1 TAB $14.34 250 $10.04 $7.17 $11.47 65% 80% 50% 50% 65% 65% 65% PHARMACY EPLERENONE 50 MG TAB (NF) 1 TAB $14.58 250 $10.21 $7.29 $11.66 65% 80% 50% 50% 65% 65% 65% PHARMACY "EPOETIN ALFA 10,000 UNITS/ML 1 ML" 1 ML J0885 $696.36 636 $487.45 $348.18 $557.09 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EPOETIN ALFA 2000 UNITS/ML 1 ML 1 ML J0885 $139.27 636 $97.49 $69.64 $111.42 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EPOETIN ALFA 20000 UNITS/ML SOL 1 ML VIAL 1 ML J0885 "$2,244.90 " 636 "$1,571.43 " "$1,122.45 " "$1,795.92 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ERAVACYCLINE 50 MG (SDV) INJ - NF J0122 $183.75 636 $128.63 $91.88 $147.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ERGOCALC 8000 UNITS/ML ORAL SYG 1 ML $5.84 250 $4.09 $2.92 $4.68 65% 80% 50% 50% 65% 65% 65% PHARMACY ERGOCALCIFEROL 50000 UNITS CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ERIBULIN 1 MG/2 ML INJ (SDV) - NF 2 ML J9179 "$2,845.60 " 636 "$1,991.92 " "$1,422.80 " "$2,276.48 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ERLOTINIB 150 MG TAB - NF 1 TAB "$1,131.03 " 250 $791.72 $565.52 $904.83 65% 80% 50% 50% 65% 65% 65% PHARMACY ERTAPENEM 1 G (SDV) INJ 10 ML J1335 $491.69 636 $344.19 $245.85 $393.36 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ERYTHROMYCIN 0.5% OPHT OIN 3.5 GM 0.5 INCH $62.86 250 $44.00 $31.43 $50.29 65% 80% 50% 50% 65% 65% 65% PHARMACY ERYTHROMYCIN 250 MG TAB UD 1 TAB $13.94 250 $9.76 $6.97 $11.16 65% 80% 50% 50% 65% 65% 65% PHARMACY ERYTHROMYCIN 500 MG COATED TAB 1 TAB $69.80 250 $48.86 $34.90 $55.84 65% 80% 50% 50% 65% 65% 65% PHARMACY ERYTHROMYCIN ETH 200MG SUS 100ML 5 ML $79.01 250 $55.31 $39.50 $63.21 65% 80% 50% 50% 65% 65% 65% PHARMACY ERYTHROMYCIN ETH 200MG/5 ML ORAL SYG 5 ML $70.95 250 $49.66 $35.47 $56.76 65% 80% 50% 50% 65% 65% 65% PHARMACY ERYTHROMYCIN ETHYLSUC 400 MG TAB UD 1 TAB $12.40 250 $8.68 $6.20 $9.92 65% 80% 50% 50% 65% 65% 65% PHARMACY ERYTHROMYCIN LACTOBION 500 MG INJ VL 10 ML J1364 "$3,418.66 " 636 "$2,393.06 " "$1,709.33 " "$2,734.93 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ERYTHROMYCIN OPHTHALMIC 0.5% OIN UD (1 GM) 0.5 INCH $35.76 250 $25.03 $17.88 $28.61 65% 80% 50% 50% 65% 65% 65% PHARMACY ERYTHROMYCIN TOP 2% SOL 60ML BTL 1 APP $175.00 250 $122.50 $87.50 $140.00 65% 80% 50% 50% 65% 65% 65% PHARMACY ESCITALOPRAM 10 MG TAB - NF 1 TAB $15.33 250 $10.73 $7.67 $12.27 65% 80% 50% 50% 65% 65% 65% PHARMACY ESCITALOPRAM 20 MG TAB UD (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ESCITALOPRAM 5 MG TAB 1 TAB $50.81 250 $35.57 $25.41 $40.65 65% 80% 50% 50% 65% 65% 65% PHARMACY ESMOLOL 10 MG/ML INJ 10 ML VL 10 ML $30.80 250 $21.56 $15.40 $24.64 65% 80% 50% 50% 65% 65% 65% PHARMACY ESOMEPRAZOLE 10 MG PWD UD 1 EA $34.14 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ESOMEPRAZOLE 20 MG DRC UD 1 CAP $10.39 250 $7.27 $5.19 $8.31 65% 80% 50% 50% 65% 65% 65% PHARMACY ESOMEPRAZOLE 40 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ESTRADIOL 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ESTRADIOL 100MCG/24 HOURS WEEKLY TER 1 PATCH $81.23 250 $56.86 $40.61 $64.98 65% 80% 50% 50% 65% 65% 65% PHARMACY ESTRADIOL 2 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ESTRADIOL 25 MCG/24 HOURS WEEKLY PAT 1 PATCH $81.23 250 $56.86 $40.61 $64.98 65% 80% 50% 50% 65% 65% 65% PHARMACY ESTRADIOL 37.5 MCG/24 HOURS WEEKLY PAT 1 PATCH $81.23 250 $56.86 $40.61 $64.98 65% 80% 50% 50% 65% 65% 65% PHARMACY ESTRADIOL 50MCG/24 HOURS WEEKLY TER 1 PATCH $77.35 250 $54.15 $38.68 $61.88 65% 80% 50% 50% 65% 65% 65% PHARMACY ESTRADIOL VALERATE 20 MG/ML INJ 5 ML 1 ML J1380 $785.68 636 $549.98 $392.84 $628.54 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ESTRADIOL VALERATE 40 MG/ML INJ 5 ML (NF) 1 ML J1380 $260.66 636 $182.46 $130.33 $208.53 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ESTROGEN CONJ 625 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ESTROGEN CONJ VAG CRE 30GM TU 1 APP "$1,696.83 " 250 "$1,187.78 " $848.42 "$1,357.47 " 65% 80% 50% 50% 65% 65% 65% PHARMACY ETANERCEPT 50 MG/ML INJ - NF 1 ML J1438 "$6,266.57 " 636 "$4,386.60 " "$3,133.28 " "$5,013.25 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ETHACRYNIC ACID 25 MG TAB (NF) 1 TAB $13.22 250 $9.26 $6.61 $10.58 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHAMBUTOL 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHAMBUTOL 400 MG TAB UD 1 EA $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHAMBUTOL 50 MG/ML ORAL SUSP 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHANOL (ETHYL ALCOHOL) 98% INJ 5ML 5 ML "$1,954.56 " 250 "$1,368.19 " $977.28 "$1,563.65 " 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHANOL 98% INJ 1ML AMP 1 ML $43.75 250 $30.63 $21.88 $35.00 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHANOLAMINE OLEATE 5% INJ 2ML AMP (SDV) 2 ML J1430 "$1,849.41 " 636 "$1,294.59 " $924.71 "$1,479.53 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ETHIN/ESTRAD/NORELGESTROMIN 35/150/24HR PATCH 1 PATCH J7304 $178.14 636 $124.70 $89.07 $142.51 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ETHINYL ESTRADIOL-NORETHINDRONE 35 MCG-1 MG TAB #28 PKT 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHINYL ESTRADIOL-NORGES 35MCG/0.25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHINYL ESTRADIOL-NORGESTIMATE TRIPHASIC 25 MCG TAB 1 TAB $22.39 250 $15.67 $11.20 $17.91 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHINYL ESTRADIOL-NORGESTIMATE TRIPHASIC 35 MCG TAB 1 TAB $137.62 250 $96.33 $68.81 $110.10 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHIODIZED OIL 480 MG/ML (LIPIODOL) INJ 1 ML "$4,678.80 " 250 "$3,275.16 " "$2,339.40 " "$3,743.04 " 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHIONAMIDE 250 MG TAB 1 TAB $6.76 250 $4.73 $3.38 $5.41 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHOSUXIMIDE 250 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ETHOSUXIMIDE 250MG/5ML ORAL SYG 5 ML $8.68 250 $6.08 $4.34 $6.95 65% 80% 50% 50% 65% 65% 65% PHARMACY ETOMIDATE 2 MG/ML INJ 10 ML VL 1 ML $26.12 250 $18.29 $13.06 $20.90 65% 80% 50% 50% 65% 65% 65% PHARMACY ETOMIDATE 2 MG/ML SOL 20 ML VL 1 ML $56.70 250 $39.69 $28.35 $45.36 65% 80% 50% 50% 65% 65% 65% PHARMACY ETONOGESTREL (NEXPLANON) 68 MG IMPLANT 1 KIT J7307 "$4,328.69 " 636 "$3,030.08 " "$2,164.34 " "$3,462.95 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ETOPOSIDE 20 MG/ML INJ 50 ML VL 1 ML J9181 $202.65 636 $141.86 $101.33 $162.12 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ETOPOSIDE 20 MG/ML INJ 5ML VL 1 ML J9181 $109.00 636 $76.30 $54.50 $87.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ETOPOSIDE 50 MG CAP 1 CAP J8560 $173.66 636 $121.56 $86.83 $138.93 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ETRAVIRINE 100 MG TAB 1 TAB $14.33 250 $10.03 $7.17 $11.46 65% 80% 50% 50% 65% 65% 65% PHARMACY ETRAVIRINE 200 MG TAB 1 TAB $98.81 250 $69.16 $49.40 $79.04 65% 80% 50% 50% 65% 65% 65% PHARMACY EVEROLIMUS 10 MG TAB (NF) 1 TAB J7527 "$2,355.86 " 636 "$1,649.10 " "$1,177.93 " "$1,884.69 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EVG/C/TAF/FTC (GENVOYA) 1 TAB $475.13 250 $332.59 $237.56 $380.10 65% 80% 50% 50% 65% 65% 65% PHARMACY EXEMESTANE 25 MG TAB 1 TAB S0156 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY EXENATIDE 2 MG PEN $795.10 250 $556.57 $397.55 $636.08 65% 80% 50% 50% 65% 65% 65% PHARMACY EZETIMIBE 10 MG TAB UD (NF) 1 TAB $48.30 250 $33.81 $24.15 $38.64 65% 80% 50% 50% 65% 65% 65% PHARMACY FAMCICLOVIR 500 MG TAB UD - NF 1 TAB $45.21 250 $31.65 $22.61 $36.17 65% 80% 50% 50% 65% 65% 65% PHARMACY FAMOTIDINE 10 MG/ML INJ 2ML VL 2 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY FAMOTIDINE 20 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FAMOTIDINE 40 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FAMOTIDINE 40 MG/5 ML ORAL LIQ 1 ML $12.39 250 $8.67 $6.19 $9.91 65% 80% 50% 50% 65% 65% 65% PHARMACY FAM-TRASTUZUMAB DERUXTECAN 100 MG (SDV) INJ J9358 "$9,934.55 " 636 "$6,954.19 " "$4,967.28 " "$7,947.64 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FAT EMULSION 20% 100 ML BAG 100 ML $320.90 250 $224.63 $160.45 $256.72 65% 80% 50% 50% 65% 65% 65% PHARMACY FAT EMULSION 20% INJ 500ML BAG (FOR PAIN CLINIC) 500 ML $178.49 250 $124.94 $89.24 $142.79 65% 80% 50% 50% 65% 65% 65% PHARMACY "FAT EMULSION, INTRAVENOUS 20% 1000 ML" 1000 ML $288.26 250 $201.78 $144.13 $230.61 65% 80% 50% 50% 65% 65% 65% PHARMACY FAT LIPID EMULSION (SMOFLIPID) 20 G/100 ML - NF 1 ML $92.40 250 $64.68 $46.20 $73.92 65% 80% 50% 50% 65% 65% 65% PHARMACY FEBUXOSTAT 40 MG TAB - NF 1 TAB $46.20 250 $32.34 $23.10 $36.96 65% 80% 50% 50% 65% 65% 65% PHARMACY FEBUXOSTAT 80 MG TAB - NF 1 TAB $46.20 250 $32.34 $23.10 $36.96 65% 80% 50% 50% 65% 65% 65% PHARMACY FELBAMATE 600 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FENOFIBRATE 134 MG CAP (NF) 1 CAP $6.86 250 $4.80 $3.43 $5.49 65% 80% 50% 50% 65% 65% 65% PHARMACY FENOFIBRATE 145 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FENOFIBRATE 160 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FENOFIBRATE 160 MG TAB 1 TAB $8.32 250 $5.82 $4.16 $6.65 65% 80% 50% 50% 65% 65% 65% PHARMACY FENOFIBRATE 54 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FENOFIBRATE 54 MG TAB (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FENTANYL 100 MCG/HR PATCH 1 PATCH $186.76 250 $130.73 $93.38 $149.41 65% 80% 50% 50% 65% 65% 65% PHARMACY FENTANYL 12 MCG/HR PATCH 1 PATCH $71.06 250 $49.74 $35.53 $56.85 65% 80% 50% 50% 65% 65% 65% PHARMACY FENTANYL 25 MCG/HR PATCH 1 PATCH $50.47 250 $35.33 $25.24 $40.38 65% 80% 50% 50% 65% 65% 65% PHARMACY FENTANYL 50 MCG/HR PATCH 1 PATCH $92.26 250 $64.58 $46.13 $73.81 65% 80% 50% 50% 65% 65% 65% PHARMACY FENTANYL 50 MCG/ML INJ 20 ML 1 EA J3010 $10.00 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FENTANYL 50 MCG/ML INJ 5 ML 5 ML J3010 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FENTANYL 50 MCG/ML INJ 50ML VL 1 ML J3010 $74.80 636 $52.36 $37.40 $59.84 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FENTANYL 50MCG/ML INJ 2ML AMP 2 ML J3010 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FENTANYL 50MCG/ML INJ 20 ML 1 ML J3010 $23.05 636 $16.14 $11.53 $18.44 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FENTANYL 75 MCG/HR PATCH 1 PATCH $140.74 250 $98.51 $70.37 $112.59 65% 80% 50% 50% 65% 65% 65% PHARMACY FERRIC SUBSULFATE TOPICAL SOLUTION 1 APP $6.49 250 $4.55 $3.25 $5.19 65% 80% 50% 50% 65% 65% 65% PHARMACY FERROUS SULF 300 MG/5 ML (12 MG/ML ELEMENTAL IRON) ADULT LIQ 5 ML $14.25 250 $9.98 $7.13 $11.40 65% 80% 50% 50% 65% 65% 65% PHARMACY FERROUS SULFATE 325 MG EC TAB UD - NF 1 TAB $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% PHARMACY FERROUS SULFATE 325 MG TAB (IRON 65 MG) UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FERROUS SULFATE 75 MG/ML (15 MG/ML ELEMENTATAL IRON) ORAL SYR 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FESOTERODINE 4 MG ER 1 TAB $50.21 250 $35.14 $25.10 $40.17 65% 80% 50% 50% 65% 65% 65% PHARMACY FESOTERODINE 8 MG ER 1 TAB $50.21 250 $35.14 $25.10 $40.17 65% 80% 50% 50% 65% 65% 65% PHARMACY FEXOFENADINE 180 MG TAB UD (NF) 1 TAB $8.46 250 $5.92 $4.23 $6.77 65% 80% 50% 50% 65% 65% 65% PHARMACY FIBRINOLYSIS INHIBITOR-THROMBIN TOP 4 ML KIT 1 KIT C9250 $0.00 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FIBRINOLYSIS INHIBITOR-THROMBIN TOPICAL 10 ML KIT 1 KIT C9250 "$2,485.74" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FIDAXOMICIN 200 MG TAB - NF 1 TAB $895.06 250 $626.54 $447.53 $716.05 65% 80% 50% 50% 65% 65% 65% PHARMACY FILGRASTIM 30 MCG/ML (DIL 1:10 D5W) 1 ML J1442 $132.23 636 $92.56 $66.12 $105.78 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FILGRASTIM 300 MCG/ML INJ 1ML VL 1 ML J1442 "$1,322.30 " 636 $925.61 $661.15 "$1,057.84 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FILGRASTIM 480 MCG/1.6 ML VL 1.6 ML J1442 "$2,105.58 " 636 "$1,473.91 " "$1,052.79 " "$1,684.47 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FILGRASTIM-SNDZ 300 MCG/0.5 ML INJ (ZARXIO) 0.5 ML Q5101 "$2,304.61 " 636 "$1,613.23 " "$1,152.31 " "$1,843.69 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FILGRASTIM-SNDZ 480 MCG/0.8 ML INJ (ZARXIO) 0.8 ML Q5101 "$2,304.66 " 636 "$1,613.26 " "$1,152.33 " "$1,843.73 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FINASTERIDE 5 MG TAB UD 1 TAB S0138 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FINGOLIMOD 0.5 MG CAP - NF 1 CAP "$1,273.35 " 250 $891.34 $636.67 "$1,018.68 " 65% 80% 50% 50% 65% 65% 65% PHARMACY FLECAINIDE 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLECAINIDE 150 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLECAINIDE 50 MG TAB 1 TAB $7.07 250 $4.95 $3.53 $5.66 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUCONAZOLE 10 MG/ML ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUCONAZOLE 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUCONAZOLE 150 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUCONAZOLE 200 MG INJ 100 ML NS PREMIX BAG 100 ML J1450 $78.38 636 $54.86 $39.19 $62.70 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUCONAZOLE 200 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUCONAZOLE 40 MG/ML ORAL SYG 1 ML $13.04 250 $9.13 $6.52 $10.43 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUCONAZOLE 400 MG INJ 200 ML NS PREMIX BAG 200 ML J1450 $102.41 636 $71.69 $51.20 $81.93 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUCONAZOLE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUCYTOSINE 10 MG/ML ORAL SYRG (PED) 1 ML $81.06 250 $56.74 $40.53 $64.85 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUCYTOSINE 250 MG CAP 1 CAP $221.81 250 $155.26 $110.90 $177.45 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUCYTOSINE 500 MG CAP 1 CAP $324.95 250 $227.46 $162.47 $259.96 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUDARABINE 25 MG/ML INJ (SDV) 2 ML 2 ML J9185 $177.09 636 $123.96 $88.54 $141.67 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUDROCORTISONE 100 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUMAZENIL 100MCG/ML INJ 5ML VL 5 ML $27.30 250 $19.11 $13.65 $21.84 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUNISOLIDE NASAL 25 MCG/INH SPR 25 ML CAN 1 SPRAY $312.66 250 $218.86 $156.33 $250.12 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOCINOLONE 0.01% SOL 60 ML BTL 1 APP $315.00 250 $220.50 $157.50 $252.00 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOCINONIDE 0.05% CRE 60GM TU 1 APP $637.67 250 $446.37 $318.83 $510.13 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOCINONIDE 0.05% CRE 15GM TU 1 APP $159.43 250 $111.60 $79.71 $127.54 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOCINONIDE 0.05% GEL 60GM 1 APP $833.74 250 $583.61 $416.87 $666.99 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOCINONIDE 0.05% OIN 15GM TU 1 APP $247.63 250 $173.34 $123.81 $198.10 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOCINONIDE 0.05% OIN 60GM 1 APP $209.23 250 $146.46 $104.61 $167.38 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOCINONIDE TOPICAL 0.05% CRE 30G 1 APP $318.85 250 $223.20 $159.43 $255.08 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOCINONIDE TOPICAL 0.05% GEL 30 GM (NF) 1 APP $416.88 250 $291.82 $208.44 $333.51 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUORESCEIN 10% INJ 5ML AMP 5 ML $159.69 250 $111.78 $79.84 $127.75 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUORESCEIN NA STRIP 1 MG EA 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUORESCEIN-PROPARACAINE OPHTHALMIC 0.25%-0.5% SOL 1 GTT $30.94 250 $21.66 $15.47 $24.75 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOROMETHOLONE OPHT 0.1% SUS 5ML 1 GTT $300.27 250 $210.19 $150.13 $240.21 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOROMETHOLONE OPHTHALMIC 0.1% SUSP 10 ML 1 GTT $596.75 250 $417.73 $298.38 $477.40 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOROURACIL 25 MG/ML OPHTH 1 ML J9190 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUOROURACIL 50 MG / 3 ML OPHTH 3 ML J9190 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUOROURACIL 50 MG/ML INJ 100 ML 1 ML J9190 $122.22 636 $85.55 $61.11 $97.78 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUOROURACIL 50 MG/ML INJ 50 ML 1 ML J9190 $118.88 636 $83.21 $59.44 $95.10 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUOROURACIL TOPICAL 5% CRE 40 GM 1 APP "$1,347.29 " 250 $943.10 $673.65 "$1,077.83 " 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOXETINE 10 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOXETINE 10 MG TAB - NF 1 TAB $10.04 250 $7.03 $5.02 $8.03 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOXETINE 20 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUOXETINE 20 MG/5 ML SOL ORAL SYR - NF 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUPHENAZINE 1 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUPHENAZINE 2.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUPHENAZINE 2.5 MG/ML INJ 10ML VL 1 ML $806.68 250 $564.68 $403.34 $645.34 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUPHENAZINE 5 MG TAB 1 TAB $4.64 250 $3.25 $2.32 $3.71 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUPHENAZINE 5 MG/ML CON (NF) 120 ML BTL 1 ML $9.99 250 $6.99 $5.00 $7.99 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUPHENAZINE DEC 25MG/ML INJ 5ML VL 5 ML J2680 $327.60 636 $229.32 $163.80 $262.08 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLURAZEPAM 15 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FLURBIPROFEN OPHT 0.03% SOL 2.5ML BTL 1 GTT $151.20 250 $105.84 $75.60 $120.96 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUTAMIDE 125 MG CAP 1 CAP S0175 $7.32 636 $5.13 $3.66 $5.86 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUTICASONE FUROATE 100 MCG DPI 1 EA $29.19 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUTICASONE FUROATE 200 MCG DPI 1 EA $39.08 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FLUTICASONE PROPIONATE HFA 110 MCG/INH INH 1 PUFF $93.05 250 $65.13 $46.52 $74.44 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUTICASONE PROPIONATE HFA 220 MCG/INH INH 1 PUFF $144.53 250 $101.17 $72.26 $115.62 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUTICASONE PROPIONATE HFA 44 MCG/INH INH 1 PUFF $78.68 250 $55.08 $39.34 $62.95 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUTICASONE SPRAY 16GM 50 MCG 1 SPRAY $73.68 250 $51.57 $36.84 $58.94 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUTICASONE-SALMETEROL 100 MCG-50 MCG PWD 1 PUFF $637.28 250 $446.10 $318.64 $509.82 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUTICASONE-SALMETEROL 250 MCG-50 MCG 1 PUFF $637.28 250 $446.10 $318.64 $509.82 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUTICASONE-SALMETEROL 500 MCG-50 MCG NF 1 INHALATION "$1,038.66 " 250 $727.06 $519.33 $830.93 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUTICASONE-VILANTEROL 100 MCG-25 MCG/INH POW 1 PUFF $602.95 250 $422.06 $301.47 $482.36 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUTICASONE-VILANTEROL 200 MCG-25 MCG/INH POW - NF 1 PUFF $585.41 250 $409.79 $292.70 $468.33 65% 80% 50% 50% 65% 65% 65% PHARMACY FLUVOXAMINE 100 MG TAB NF 1 TAB $9.24 250 $6.47 $4.62 $7.39 65% 80% 50% 50% 65% 65% 65% PHARMACY FOLIC ACID 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FOLIC ACID 1000 MCG/ML ORAL SUSP 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FOLIC ACID 5 MG/ML INJ 10 ML VL 1 ML $206.57 250 $144.60 $103.29 $165.26 65% 80% 50% 50% 65% 65% 65% PHARMACY FOMEPIZOLE 1 G/ML (SDV) INJ 1.5 ML J1451 "$6,315.00 " 636 "$4,420.50 " "$3,157.50 " "$5,052.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FONDAPARINUX 10 MG/0.8 ML SYR 0.8 ML J1652 $562.67 636 $393.87 $281.33 $450.14 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FONDAPARINUX 2.5 MG/0.5 ML SYR 0.5 ML J1652 $382.56 636 $267.79 $191.28 $306.05 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FONDAPARINUX 5 MG/0.4 ML SYR 0.4 ML J1652 "$1,125.34 " 636 $787.74 $562.67 $900.27 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FONDAPARINUX 7.5 MG/0.6 ML SYR 0.6 ML J1652 $750.23 636 $525.16 $375.11 $600.18 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FORTIFIED AMPHOTERICIN B 0.15% EYE DROP 1 GTT $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FORTIFIED BACITRACIN EYE DROP 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FORTIFIED CEFAZOLIN EYE DROP 10 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FORTIFIED GENTAMICIN EYE DROP 7 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FORTIFIED VANCOMYCIN EYE DROP 14MG/ML OPTH GTTS 1 GTT $15.41 250 $10.79 $7.71 $12.33 65% 80% 50% 50% 65% 65% 65% PHARMACY FORTIFIED VANCOMYCIN EYE DROP 50MG/ML OPTH GTTS 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FORTIFIED VORICONIZOLE EYE DROP 20 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FOSAMPRENAVIR 700 MG TAB 1 TAB $22.89 250 $16.02 $11.44 $18.31 65% 80% 50% 50% 65% 65% 65% PHARMACY FOSCARNET 24 MG/ML INJ 250 ML BTL 1 ML J1455 "$2,010.56 " 636 "$1,407.39 " "$1,005.28 " "$1,608.45 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FOSFOMYCIN 3 G POW $383.32 250 $268.32 $191.66 $306.66 65% 80% 50% 50% 65% 65% 65% PHARMACY FOSPHENYTOIN 500 MG PE/10 ML VL 10 ML Q2009 $199.50 636 $139.65 $99.75 $159.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FOSPHENYTOIN 50MG PE/ML 2ML VL 2 ML Q2009 $63.00 636 $44.10 $31.50 $50.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FULVESTRANT 50 MG/ML INJ 5 ML SYR 5 ML J9395 $240.16 636 $168.11 $120.08 $192.13 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FUROSEMIDE 10 MG/ML (SDV) 10 ML 10 ML J1940 $24.15 636 $16.91 $12.08 $19.32 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FUROSEMIDE 10 MG/ML (SDV) 2 ML 2 ML J1940 $18.44 636 $12.91 $9.22 $14.75 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FUROSEMIDE 10 MG/ML (SDV) 4 ML 4 ML J1940 $13.20 636 $9.24 $6.60 $10.56 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FUROSEMIDE 10 MG/ML 4ML VL 4 ML J1940 $13.20 636 $9.24 $6.60 $10.56 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FUROSEMIDE 10 MG/ML INJ 10ML VL 10 ML J1940 $24.15 636 $16.91 $12.08 $19.32 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FUROSEMIDE 10 MG/ML INJ 2 ML VL 2 ML J1940 $18.44 636 $12.91 $9.22 $14.75 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY FUROSEMIDE 20 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FUROSEMIDE 20 MG/2ML ORAL SYG 2 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FUROSEMIDE 40 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY FUROSEMIDE 80 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GABAPENTIN 100 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GABAPENTIN 300 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GABAPENTIN 400 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GABAPENTIN 50 MG/1 ML ORAL SOL - NF 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GABAPENTIN 600 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GABAPENTIN 800 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GANCICLOVIR 500 MG INJ VL 10 ML J1570 "$10,213.35 " 636 "$7,149.35 " "$5,106.68 " "$8,170.68 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GANCICLOVIR OPHTHALMIC 0.15% GEL - NF 1 APP $331.53 250 $232.07 $165.77 $265.23 65% 80% 50% 50% 65% 65% 65% PHARMACY GATIFLOXACIN OPHTHALMIC 0.3% SOLN 5ML (NF) 1 GTT $304.85 250 $213.40 $152.43 $243.88 65% 80% 50% 50% 65% 65% 65% PHARMACY GEMCITABINE 1000 MG (SDV) INJ - NF J9201 $120.44 636 $84.31 $60.22 $96.35 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GEMCITABINE 38 MG/ML (SDV) 26.3 ML 26.3 ML J9201 $123.53 636 $86.47 $61.76 $98.82 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GEMCITABINE 38 MG/ML INJ (SDV) 5.26 ML 5.26 ML J9201 $106.05 636 $74.23 $53.02 $84.84 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GEMFIBROZIL 600 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GEMTUZUMAB OZOGAMICIN 4.5 MG (SDV) INJ - NF J9203 $990.16 636 $693.11 $495.08 $792.13 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GENTAMICIN 10 MG/ML INJ 2ML VL 2 ML J1580 $18.02 636 $12.61 $9.01 $14.41 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GENTAMICIN 100MG INJ 100 ML PREMIX BAG 100 ML J1580 $16.47 636 $11.53 $8.23 $13.17 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GENTAMICIN 120 MG/100 ML INJ PREMIX BAG 100 ML J1580 $16.04 636 $11.23 $8.02 $12.84 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GENTAMICIN 40 MG/ML (SDV) INJ 2ML 2 ML J1580 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GENTAMICIN 40 MG/ML INJ 20ML VL 20 ML J1580 $97.48 636 $68.24 $48.74 $77.99 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GENTAMICIN 60 MG INJ 50 ML PREMIX BAG 50 ML J1580 $14.75 636 $10.32 $7.37 $11.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GENTAMICIN 80 MG INJ 100 ML PREMIX BAG 100 ML J1580 $15.38 636 $10.76 $7.69 $12.30 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GENTAMICIN OPHT 0.3% OIN 3.5 GM TU 0.5 INCH $136.32 250 $95.43 $68.16 $109.06 65% 80% 50% 50% 65% 65% 65% PHARMACY GENTAMICIN OPHT 0.3% SOL 5ML BTL 1 BTL $4.20 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GENTAMICIN OPHT 0.3% SOL 5ML BTL 1 GTT $67.13 250 $46.99 $33.57 $53.70 65% 80% 50% 50% 65% 65% 65% PHARMACY GENTAMICIN OPHT 0.3% SOL OPHTH 1 GTT $13.43 250 $9.40 $6.71 $10.74 65% 80% 50% 50% 65% 65% 65% PHARMACY GENTAMICIN TOP 0.1% OIN 15GM TU 1 APP $172.83 250 $120.98 $86.42 $138.26 65% 80% 50% 50% 65% 65% 65% PHARMACY GENTIAN VIOLET TOPICAL 1% SOL 30ML (NF) 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GENTIAN VIOLET TOPICAL 1% SOLN 60 ML 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GLATIRAMER 20 MG/ML - NF 1 ML J1595 $995.96 636 $697.17 $497.98 $796.77 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GLECAPREVIR-PIBRENTASVIR 100 MG-40 MG TAB 1 TAB $660.00 250 $462.00 $330.00 $528.00 65% 80% 50% 50% 65% 65% 65% PHARMACY GLIPIZIDE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GLIPIZIDE 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GLUCAGON RECOMB 1 MG 1 ML J1610 $716.10 636 $501.27 $358.05 $572.88 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GLUCARPIDASE 1000 UNITS C9293 "$94,500.00 " 636 "$66,150.00 " "$47,250.00 " "$75,600.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GLUCOSE 15G ORAL GEL TUBE 1 EA $5.53 250 $3.87 $2.76 $4.42 65% 80% 50% 50% 65% 65% 65% PHARMACY GLUCOSE 4 G TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYBURIDE 1.25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYBURIDE 2.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYBURIDE 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYCERIN ADULT SUPP 1 SUPP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYCERIN PEDIATRIC SUPP 1 SUPP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYCERIN SOL 100% 480ML 480 ML $94.08 250 $65.86 $47.04 $75.26 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYCOPYRROLATE 0.2 MG/ML PF INJ - NF 1 ML $15.96 250 $11.17 $7.98 $12.77 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYCOPYRROLATE 1 MG TAB - NF 1 TAB $24.80 250 $17.36 $12.40 $19.84 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYCOPYRROLATE 2 MG TAB - NF 1 TAB $7.70 250 $5.39 $3.85 $6.16 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYCOPYRROLATE 200 MCG/ML INJ 1 ML VL 1 ML $56.88 250 $39.81 $28.44 $45.50 65% 80% 50% 50% 65% 65% 65% PHARMACY GLYCOPYRROLATE 200 MCG/ML INJ 5ML VL 1 ML $47.95 250 $33.57 $23.98 $38.36 65% 80% 50% 50% 65% 65% 65% PHARMACY GOSERELIN 10.8 MG (ZOLADEX) IMPLANT J9202 "$8,796.55 " 636 "$6,157.59 " "$4,398.28 " "$7,037.24 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GOSERELIN 3.6 MG (ZOLADEX) IMPLANT 1 SYRINGE J9202 "$1,168.23 " 636 $817.76 $584.12 $934.59 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GRANISETRON 1 MG/ML INJ 1ML VL 1 ML J1626 $37.80 636 $26.46 $18.90 $30.24 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY GRISEOFULVIN MICRO 125 MG/5 ML ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GRISEOFULVIN MICROCRYSTALLINE 500 MG TAB 1 TAB $29.78 250 $20.85 $14.89 $23.82 65% 80% 50% 50% 65% 65% 65% PHARMACY GUAIFENESIN 100 MG/5 ML LIQ UD 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GUANFACINE 1 MG ER - NF 1 TAB $36.72 250 $25.70 $18.36 $29.38 65% 80% 50% 50% 65% 65% 65% PHARMACY GUANFACINE 1 MG TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY GUANFACINE 2 MG ER - NF 1 TAB $36.72 250 $25.70 $18.36 $29.38 65% 80% 50% 50% 65% 65% 65% PHARMACY GUSELKUMAB 100 MG/ML INJ - NF 1 ML J1628 "$50,141.14 " 636 "$35,098.80 " "$25,070.57 " "$40,112.91 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HALOPERIDOL 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HALOPERIDOL 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HALOPERIDOL 2 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HALOPERIDOL 2 MG/ML SOL ORAL SYG 5 ML $46.66 250 $32.66 $23.33 $37.32 65% 80% 50% 50% 65% 65% 65% PHARMACY HALOPERIDOL 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HALOPERIDOL 5 MG/ML (SDV) INJ 1ML 1 ML J1630 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HALOPERIDOL 500 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HALOPERIDOL DECANOATE 100 MG/ML (SDV) INJ 1ML 1 ML J1631 $154.81 636 $108.36 $77.40 $123.84 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HALOPERIDOL DECANOATE 50 MG/ML (SDV) INJ 1 ML J1631 $92.40 636 $64.68 $46.20 $73.92 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "HEPARIN 10,000 UNITS/ML INJ 5 ML VL" 1 ML J1644 $107.81 636 $75.47 $53.91 $86.25 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN 1000 UNITS/ML INJ 10 ML VL 1 ML J1644 $16.63 636 $11.64 $8.32 $13.31 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN 1000 UNITS/ML INJ 1ML VL 1 ML J1644 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN 25000 UNITS IN D5W 250 ML 250 ML J1644 "$5,390.70" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN 5000 UNITS/ML INJ 1ML 1 ML J1644 $17.47 636 $12.23 $8.74 $13.98 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN FLUSH 1 UNIT/ML INJ 1 ML J1642 $13.27 636 $9.29 $6.63 $10.61 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN FLUSH 10 UNITS/ML 3ML SYR 3 ML J1642 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN FLUSH 10 UNITS/ML 5 ML SYR 5 ML J1642 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN FLUSH 10 UNITS/ML INJ 1ML 1 ML J1642 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN FLUSH 100 UNITS/ML 1ML VL 1 ML J1642 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPARIN FLUSH 100 UNITS/ML 5 ML SYR 5 ML J1642 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPATITIS A 1440 UNITS (ADULT) VAC PF INJ 1 ML 1 ML $300.30 250 $210.21 $150.15 $240.24 65% 80% 50% 50% 65% 65% 65% PHARMACY HEPATITIS A 720 UNITS (PED) VACCINE PF INJ 0.5 ML 0.5 ML $141.66 250 $99.16 $70.83 $113.33 65% 80% 50% 50% 65% 65% 65% PHARMACY HEPATITIS A-HEPATITIS B VACCINE 720 UNITS-20 MCG/ML PF INJ 1 ML 1 ML $457.28 250 $320.09 $228.64 $365.82 65% 80% 50% 50% 65% 65% 65% PHARMACY HEPATITIS B (ADULT) VACCINE 20 MCG/ML (ENGERIX) INJ 1 ML 1 ML $259.29 250 $181.50 $129.64 $207.43 65% 80% 50% 50% 65% 65% 65% PHARMACY HEPATITIS B (PED) VACCINE 10 MCG/0.5 ML (ENGERIX) INJ 0.5 ML 0.5 ML $207.85 250 $145.50 $103.93 $166.28 65% 80% 50% 50% 65% 65% 65% PHARMACY HEPATITIS B ADULT VACCINE (HEPLISAV-B) 20 MCG/0.5 ML 0.5 ML "$1,062.60 " 250 $743.82 $531.30 $850.08 65% 80% 50% 50% 65% 65% 65% PHARMACY HEPATITIS B IMMUNE GLOBULIN VL 1 ML 1 ML J1571 $577.64 636 $404.35 $288.82 $462.11 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HEPATITIS B IMMUNE GLOBULIN 5ML VL 5 ML J1571 "$2,979.97 " 636 "$2,085.98 " "$1,489.99 " "$2,383.98 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HIB (ACTHIB) VACCINE INJ 0.5 ML - NF 0.5 ML $73.53 250 $51.47 $36.76 $58.82 65% 80% 50% 50% 65% 65% 65% PHARMACY HIB (PEDVAXHIB) VACCINE INJ 0.5 ML 0.5 ML $114.65 250 $80.25 $57.32 $91.72 65% 80% 50% 50% 65% 65% 65% PHARMACY HISTRELIN 50 MG IMP 1 KIT J9225 "$20,470.21 " 636 "$14,329.14 " "$10,235.10 " "$16,376.16 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HPV - HUMAN PAPILLOMAVIRUS (GARDASIL 9-VALENT) VACCINE 0.5 ML "$2,123.96 " 250 "$1,486.77 " "$1,061.98 " "$1,699.17 " 65% 80% 50% 50% 65% 65% 65% PHARMACY HYALURONAN 30 MG/2 ML INJ - NF 2 ML J7324 "$2,007.60 " 636 "$1,405.32 " "$1,003.80 " "$1,606.08 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYALURONAN 88 MG/4 ML (MONOVISC) INJ - NF 4 ML J7327 "$1,575.00 " 636 "$1,102.50 " $787.50 "$1,260.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYALURONIDASE 200 UNITS/ML SOL 1.2 ML J3470 $455.94 636 $319.16 $227.97 $364.76 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDRALAZINE 1 MG/ML (DIL 1:20 NS) 1 ML J0360 $54.94 636 $38.46 $27.47 $43.95 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDRALAZINE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDRALAZINE 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDRALAZINE 20 MG/ML (SDV) INJ 1 ML 1 ML J0360 $54.94 636 $38.46 $27.47 $43.95 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDRALAZINE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDRALAZINE 2MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDRALAZINE 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCHLOROTHIAZIDE 12.5 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCHLOROTHIAZIDE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCHLOROTHIAZIDE 5MG/ML ORAL SYR 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCHLOROTHIAZIDE-LOSARTAN 12.5 MG-50 MG TAB UD NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE 1% OIN 30GM TU 1 APP $14.96 250 $10.47 $7.48 $11.97 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE 10% RECTAL FOAM 15GM 1 APP "$1,429.68 " 250 "$1,000.78 " $714.84 "$1,143.74 " 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE 100 MG ENEMA 60ML $90.00 250 $63.00 $45.00 $72.00 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE 250 MG PF INJ 5 ML J1720 $114.10 636 $79.87 $57.05 $91.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROCORTISONE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE PF 1 MG/ML (DIL 1:50 NS) 1 ML J1720 $56.41 636 $39.48 $28.20 $45.12 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROCORTISONE PF VL 100 MG/2 ML 2 ML J1720 $64.82 636 $45.37 $32.41 $51.86 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROCORTISONE SOD SUCC 5MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE TOPICAL 1% CREAM 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE TOPICAL 25 MG SUP UD (NF) 1 SUPP $50.49 250 $35.34 $25.24 $40.39 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE VAL 0.2% OIN 15GM TU 1 APP $344.40 250 $241.08 $172.20 $275.52 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE-PRAMOXINE RECTAL 1%-1% FOAM 1 APP $659.68 250 $461.78 $329.84 $527.74 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROCORTISONE-PRAMOXINE TOPICAL FOAM 10GM 1 APP $339.82 250 $237.87 $169.91 $271.85 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROGEN PEROXID 3% SOL 480 ML BTL 1 APP $33.68 250 $23.58 $16.84 $26.95 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROMORPHONE 1 MG/ML INJ 1ML SYG 1 ML J1170 $17.43 636 $12.20 $8.72 $13.94 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROMORPHONE 1 MG/ML ORAL LIQ 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROMORPHONE 1 MG/ML PCA 30 ML 30 ML J1170 $56.88 636 $39.81 $28.44 $45.50 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROMORPHONE 10 MG/ML INJ **FOR PCA PREP\COMPOUND** 1 ML J1170 $509.38 636 $356.56 $254.69 $407.50 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROMORPHONE 2 MG TAB (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROMORPHONE 2 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROMORPHONE 2 MG/ML 20 ML 1 EA J1170 $4.50 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROMORPHONE 2 MG/ML INJ 1 ML SYG 1 ML J1170 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROMORPHONE 4 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROMORPHONE 8 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROQUINONE TOPICAL 4% TOPICAL CREAM 1 APP $13.20 250 $9.24 $6.60 $10.56 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROXOCOBALAMIN 5 G POW 1 EA "$2,727.73 " 250 "$1,909.41 " "$1,363.86 " "$2,182.18 " 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROXYCHLOROQUINE 200 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROXYCHLOROQUINE 25 MG/ML SUSP 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROXYETHYL STARCH 6%-NACL 0.9% SOL 500 ML $322.49 250 $225.74 $161.25 $257.99 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROXYPRO METHYL OPH 2.5% 15ML BTL 1 GTT $84.70 250 $59.29 $42.35 $67.76 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROXYPROGESTERONE 250 MG/ML INJ - NF 1 ML J1726 "$14,490.00 " 636 "$10,143.00 " "$7,245.00 " "$11,592.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROXYUREA 100MG/ML SUSP 1 ML S0176 $4.00 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROXYUREA 500 MG CAP 1 CAP S0176 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROXYZINE 10 MG/5 ML ORAL SYG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROXYZINE 25 MG/ML 1ML 1 ML J3410 $89.29 636 $62.50 $44.65 $71.43 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROXYZINE HCL 50MG/ML 2ML INJ 2 ML J3410 $156.49 636 $109.54 $78.25 $125.19 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYDROXYZINE HYDROCHLORIDE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROXYZINE HYDROCHLORIDE 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYDROXYZINE PAMOATE 50 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY HYLAN G-F 20 16 MG/2 ML INJ (SYNVISC) 2 ML J7325 $958.73 636 $671.11 $479.37 $766.99 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY HYLAN G-F 20 48 MG/6 ML INJ (SYNVISC ONE) 6 ML J7325 $958.73 636 $671.11 $479.37 $766.99 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IBUPROFEN 100MG SUSP 5ML UD CUP 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IBUPROFEN 20 MG/1 ML SUSP ORAL SYRINGE 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IBUPROFEN 200 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IBUPROFEN 200 MG/10 ML SUSP UD CUP 10 ML $5.08 250 $3.56 $2.54 $4.07 65% 80% 50% 50% 65% 65% 65% PHARMACY IBUPROFEN 400 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IBUPROFEN 600 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IBUPROFEN 800 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IBUPROFEN LYSINE 10MG/ML INJ 2 ML J1741 "$1,916.20 " 636 "$1,341.34 " $958.10 "$1,532.96 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IBUPROFEN LYSINE 5 MG/ML (DIL 1:2 D5W) 1 ML J1741 $479.05 636 $335.34 $239.53 $383.24 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IBUTILIDE 100 MCG/ML INJ 10 ML VL 10 ML J1742 "$1,305.08 " 636 $913.56 $652.54 "$1,044.06 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IDARUBICIN 1 MG/ML INJ 10 ML VL 10 ML J9211 $226.37 636 $158.46 $113.18 $181.09 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IDARUBICIN 1 MG/ML INJ 20 ML 20 ML J9211 $343.80 636 $240.66 $171.90 $275.04 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IDARUBICIN 1 MG/ML INJ 5 ML VL 5 ML J9211 $164.53 636 $115.17 $82.26 $131.62 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IDARUCIZUMAB 2.5 G/50 ML INJ 50 ML "$8,986.45 " 250 "$6,290.51 " "$4,493.22 " "$7,189.16 " 65% 80% 50% 50% 65% 65% 65% PHARMACY IFOSFAMIDE 1000 MG PWD J9208 $127.04 636 $88.93 $63.52 $101.63 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IFOSFAMIDE 50 MG/ML INJ 20ML (SDV) 20 ML J9208 $197.00 636 $137.90 $98.50 $157.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IMATINIB 100 MG TAB 1 TAB $516.45 250 $361.51 $258.22 $413.16 65% 80% 50% 50% 65% 65% 65% PHARMACY IMATINIB 400 MG TAB (NF) 1 TAB "$1,289.48 " 250 $902.64 $644.74 "$1,031.58 " 65% 80% 50% 50% 65% 65% 65% PHARMACY IMIPENEM-CILASTAT 500 MG/100 ML NS PREMADE KIT 100 ML J0743 "$2,625.00 " 636 "$1,837.50 " "$1,312.50 " "$2,100.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IMIPENEM-CILASTATIN 5 MG/ML (DIL 1:10 NS) 1 ML J0743 $10.50 636 $7.35 $5.25 $8.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IMIPENEM-CILASTATIN 500 MG INJ VL 10 ML J0743 $115.00 636 $80.50 $57.50 $92.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IMIPENEM-CILASTATIN 500 MG-500 MG / 100ML 0.9% NS IVPB (NF) 100 ML J0743 $142.52 636 $99.76 $71.26 $114.02 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IMIPRAMINE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IMIPRAMINE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IMIPRAMINE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IMIQUIMOD TOP 5% CRE 0.25GM PKT 1 APP $210.00 250 $147.00 $105.00 $168.00 65% 80% 50% 50% 65% 65% 65% PHARMACY IMMUNE GLOBULIN (PRIVIGEN) INJ 10 GM (SDV) 100 ML J1459 $46.62 636 $32.63 $23.31 $37.30 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IMMUNE GLOBULIN INTRAMUSCULAR INJ 10ML 10 ML J1460 $781.55 636 $547.09 $390.78 $625.24 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IMMUNE GLOBULIN INTRAMUSCULAR INJ 2 ML 2 ML J1460 $85.54 636 $59.88 $42.77 $68.43 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INDIGO CARMINE 8 MG/ML INJ 5 ML VL 1 ML $791.36 250 $553.95 $395.68 $633.09 65% 80% 50% 50% 65% 65% 65% PHARMACY INDINAVIR 200 MG CAP - NF 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY INDINAVIR 400 MG CAP UD 1 CAP $6.61 250 $4.63 $3.31 $5.29 65% 80% 50% 50% 65% 65% 65% PHARMACY INDOCYANINE GREEN 25 MG INJ $423.65 250 $296.55 $211.82 $338.92 65% 80% 50% 50% 65% 65% 65% PHARMACY INDOMETHACIN 0.2 MG/ML (DIL 1:5 NS) 1 ML $444.31 250 $311.02 $222.16 $355.45 65% 80% 50% 50% 65% 65% 65% PHARMACY INDOMETHACIN 1 MG INJ VL 1 ML "$2,221.56 " 250 "$1,555.09 " "$1,110.78 " "$1,777.24 " 65% 80% 50% 50% 65% 65% 65% PHARMACY INDOMETHACIN 25 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY INDOMETHACIN 25 MG/5 ML SUS - NF 5 ML $173.72 250 $121.60 $86.86 $138.98 65% 80% 50% 50% 65% 65% 65% PHARMACY INDOMETHACIN 50 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY INDOMETHACIN 50 MG SUP 1 SUPP "$1,449.00 " 250 "$1,014.30 " $724.50 "$1,159.20 " 65% 80% 50% 50% 65% 65% 65% PHARMACY INFLIXIMAB (REMICADE) 100 MG PWD INJ (SDV) J1745 $716.46 636 $501.52 $358.23 $573.17 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INFLIXIMAB-DYYB 100 MG INJ (INFLECTRA) (SDV) Q5103 "$3,974.39 " 636 "$2,782.07 " "$1,987.20 " "$3,179.51 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INFLUENZA VACCINE (QUAD PF) 0.25 ML (AFLURIA) 6 MO - 35 MO 0.25 ML $25.00 250 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% 65% PHARMACY INFLUENZA VACCINE (QUAD PF) 0.5 ML (FLUARIX) 6 MO - 35 MO 0.5 ML $25.00 250 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% 65% PHARMACY INFLUENZA VACCINE (QUAD PF) 0.5 ML (FLULAVAL) 19 YR AND UP 0.5 ML $25.00 250 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% 65% PHARMACY INFLUENZA VACCINE (QUAD PF) 0.5 ML SYR (AFLURIA) 3 YR AND UP 0.5 ML $159.45 250 $111.61 $79.72 $127.56 65% 80% 50% 50% 65% 65% 65% PHARMACY INFLUENZA VACCINE (QUAD PF) 0.7 ML (FLUZONE HD) 65 YR AND UP 0.7 ML $343.48 250 $240.44 $171.74 $274.78 65% 80% 50% 50% 65% 65% 65% PHARMACY INFLUENZA VACCINE (QUAD) 0.5 ML MDV (AFLURIA) 3 YR AND UP 0.5 ML $147.37 250 $103.16 $73.69 $117.90 65% 80% 50% 50% 65% 65% 65% PHARMACY INFLUENZA VIRUS VACCINE (QUAD PF) 0.5 ML SYR (FLUBLOK) 18 YRS AND UP 0.5 ML $25.00 250 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% 65% PHARMACY INHALATION SPACER DEVICE - ADULT 1 EA $22.26 250 $15.58 $11.13 $17.81 65% 80% 50% 50% 65% 65% 65% PHARMACY INHALATION SPACER DEVICE - MEDIUM 1 EA $23.28 250 $16.29 $11.64 $18.62 65% 80% 50% 50% 65% 65% 65% PHARMACY INHALATION SPACER DEVICE - SMALL 1 EA $21.18 250 $14.82 $10.59 $16.94 65% 80% 50% 50% 65% 65% 65% PHARMACY INOTUZUMAB OZOGAMICIN 0.9 MG (SDV) INJ J9229 "$85,841.53 " 636 "$60,089.07 " "$42,920.77 " "$68,673.23 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN 70/30 SUS 3 ML 0.01 ML J1815 $62.45 636 $43.72 $31.23 $49.96 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN ASPART 100 UNITS/ML INJ 1 ML J1815 "$1,215.31 " 636 $850.71 $607.65 $972.24 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN ASPART-INSULIN ASPART PROTAMINE 30 UNITS-70 UNITS/ML SUS - NF 0.01 ML J1815 $156.47 636 $109.53 $78.24 $125.18 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN GLARGINE 100 UNITS/ML 10ML VL 0.01 ML J1815 "$1,190.95 " 636 $833.66 $595.47 $952.76 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN HUMAN 70/30 10ML VL 0.01 ML J1815 $624.54 636 $437.18 $312.27 $499.63 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN HUMAN NPH 100 UNITS/ML 10ML VL 0.01 ML J1815 $624.54 636 $437.18 $312.27 $499.63 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN HUMAN NPH 100 UNITS/ML 3ML VL 0.01 ML J1815 $62.45 636 $43.72 $31.23 $49.96 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN HUMAN REG 0.1 UNIT/ML (DIL 1:1000 NS) 1 ML J1815 $15.56 636 $10.90 $7.78 $12.45 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN HUMAN REG 100 UNITS/ML 10 ML VL 0.01 ML J1815 $578.34 636 $404.84 $289.17 $462.67 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN HUMAN REG 100 UNITS/ML 3ML VL 0.01 ML J1815 $62.45 636 $43.72 $31.23 $49.96 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN LISPRO 100 UNITS/ML INJ 10ML 0.01 ML J1815 "$1,153.74 " 636 $807.62 $576.87 $922.99 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN LISPRO HUMAN VL 3ML 0.01 ML J1815 $346.11 636 $242.28 $173.06 $276.89 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INSULIN REGULAR HUMAN RECOMBINANT 500 UNITS/ML INJ - NF 20 ML J1815 "$6,245.40 " 636 "$4,371.78 " "$3,122.70 " "$4,996.32 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "INTERFERON ALFA-2B 10,000,000 INTERNATIONAL_UNITS INJ" J9214 "$1,290.66 " 636 $903.46 $645.33 "$1,032.53 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "INTERFERON ALFA-2B INJ 50,000,000 INTERNATIONAL_UNITS INJ" J9214 "$5,040.46 " 636 "$3,528.32 " "$2,520.23 " "$4,032.37 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTERFERON BETA-1A 30 MCG/0.5 ML SYRINGE (NF) 0.5 ML J1826 "$30,263.28 " 636 "$21,184.29 " "$15,131.64 " "$24,210.62 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTERFERON BETA-1A 44 MCG/0.5 ML PFS (NF) 0.5 ML Q3028 "$6,211.62 " 636 "$4,348.13 " "$3,105.81 " "$4,969.30 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTERFERON BETA-1B 0.3 MG POW J1830 "$28,065.94 " 636 "$19,646.16 " "$14,032.97 " "$22,452.75 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTERFERON BETA-1B 0.3 MG PWD INJ (NF) 1.2 ML J1830 "$2,245.28 " 636 "$1,571.69 " "$1,122.64 " "$1,796.22 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTRAVITREAL AMPHOTERICIN B 5 MCG 0.1 ML J0285 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTRAVITREAL CLINDAMYCIN 1MG/0.1 ML 1 MG INJ 1 ML S0077 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTRAVITREAL FOSCARNET 2.4 MG/0.1 ML 0.1 ML J1455 $4.86 636 $3.40 $2.43 $3.88 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTRAVITREAL GANCICLOVIR 3 MG/0.1 ML 0.1 ML J1570 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTRAVITREAL GANCICLOVIR 4 MG/0.1 ML 0.1 ML J1570 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY INTRAVITREAL GANCICLOVIR 5 MG/0.1 ML 0.1 ML J1570 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IODINE POTASSIUM IODIDE TOPICAL 5%-10% SOLUTION 1 APP $38.28 250 $26.80 $19.14 $30.63 65% 80% 50% 50% 65% 65% 65% PHARMACY IPILIMUMAB 5 MG/ML INJ 10 ML (SDV) - NF 10 ML J9228 "$12,031.50 " 636 "$8,422.05 " "$6,015.75 " "$9,625.20 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IPILIMUMAB 5 MG/ML INJ 40 ML (SDV) - NF 40 ML J9228 "$47,782.05 " 636 "$33,447.44 " "$23,891.03 " "$38,225.64 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IPRATROPIUM 0.02% INH 2.5ML UD 2.5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY IPRATROPIUM CFC FREE 17 MCG/INH AER 12.9 GM 1 PUFF "$1,796.97 " 250 "$1,257.88 " $898.49 "$1,437.58 " 65% 80% 50% 50% 65% 65% 65% PHARMACY IPRATROPIUM NASAL INH 30ML BTL 1 SPRAY $390.84 250 $273.59 $195.42 $312.68 65% 80% 50% 50% 65% 65% 65% PHARMACY "IPV (POLIOVIRUS VACCINE, INACTIVATED) VACCINE INJ (IPOL)" 0.5 ML $154.40 250 $108.08 $77.20 $123.52 65% 80% 50% 50% 65% 65% 65% PHARMACY IRINOTECAN 20 MG/ML (SDV) INJ 2ML 2 ML J9206 $108.38 636 $75.87 $54.19 $86.71 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IRINOTECAN 20 MG/ML (SDV) INJ 5 ML 5 ML J9206 $113.99 636 $79.79 $57.00 $91.19 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IRINOTECAN LIPOSOMAL 4.3 MG/ML DSP INJ (SDV) 10 ML J9205 "$2,978.48 " 636 "$2,084.94 " "$1,489.24 " "$2,382.78 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IRON SUCROSE 20 MG/ML (SDV) INJ 1 ML J1756 $211.75 636 $148.23 $105.88 $169.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ISATUXIMAB IRFC 20 MG/ML (SDV) INJ 25 ML - NF 25 ML J9227 "$9,114.36 " 636 "$6,380.05 " "$4,557.18 " "$7,291.49 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ISATUXIMAB IRFC 20 MG/ML (SDV) INJ 5 ML - NF 5 ML J9227 "$1,902.87 " 636 "$1,332.01 " $951.44 "$1,522.30 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ISAVUCONAZONIUM 186 MG CAP (ISAVUCONAZOLE 100MG) - NF 1 CAP $400.44 250 $280.31 $200.22 $320.35 65% 80% 50% 50% 65% 65% 65% PHARMACY ISAVUCONAZONIUM SULFATE 372 MG (ISAVUCONAZOLE 200MG) (SDV) INJ - NF 5 ML J1833 "$1,364.37 " 636 $955.06 $682.19 "$1,091.50 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ISOFLURANE 100% INH 100ML BTL 100 ML $52.50 250 $36.75 $26.25 $42.00 65% 80% 50% 50% 65% 65% 65% PHARMACY ISONIAZID 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ISONIAZID 300 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ISONIAZID SYRP 50 MG/5 ML ORAL SYRG 5 ML $15.12 250 $10.59 $7.56 $12.10 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOPROTERENOL 200MCG/ML INJ 1ML 1 ML "$6,184.31 " 250 "$4,329.01 " "$3,092.15 " "$4,947.44 " 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOPROTERENOL 200MCG/ML INJ 5ML 5 ML "$2,535.00 " 250 "$1,774.50 " "$1,267.50 " "$2,028.00 " 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOSORBIDE DINITRATE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOSORBIDE DINITRATE 10 MG TAB UD (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOSORBIDE DINITRATE 20 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOSORBIDE DINITRATE 30 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOSORBIDE DINITRATE 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOSORBIDE MONONITRATE 30 MG ERT UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOSORBIDE MONONITRATE 60 MG ERT 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ISOSULFAN BLUE 10 MG/ML INJ (SDV) 5 ML Q9968 $891.15 636 $623.80 $445.57 $712.92 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ISOTRETINOIN 40 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY ITRACONAZOLE 10 MG/ML ORAL SYG 1 ML $8.57 250 $6.00 $4.28 $6.85 65% 80% 50% 50% 65% 65% 65% PHARMACY ITRACONAZOLE 100 MG CAP (NF) 1 CAP $32.56 250 $22.79 $16.28 $26.05 65% 80% 50% 50% 65% 65% 65% PHARMACY ITRACONAZOLE 100 MG CAP UD 1 CAP $6.77 250 $4.74 $3.39 $5.42 65% 80% 50% 50% 65% 65% 65% PHARMACY IVERMECTIN 3 MG TAB 1 TAB $7.86 250 $5.50 $3.93 $6.29 65% 80% 50% 50% 65% 65% 65% PHARMACY IXABEPILONE 15 MG INJ - NF J9207 "$1,878.04 " 636 "$1,314.63 " $939.02 "$1,502.43 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY IXABEPILONE 45 MG INJ - NF J9207 "$5,450.00 " 636 "$3,815.00 " "$2,725.00 " "$4,360.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY KETAMINE 10 MG/0.1 ML INJ SYRINGE 0.1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY KETAMINE 10 MG/ML INJ 20 ML VIAL 1 ML $84.45 250 $59.12 $42.23 $67.56 65% 80% 50% 50% 65% 65% 65% PHARMACY KETAMINE 100 MG/ML INJ 5 ML VL 1 ML $56.02 250 $39.21 $28.01 $44.82 65% 80% 50% 50% 65% 65% 65% PHARMACY KETOCONAZOLE 2% SHAM 120ML BTL 1 APP $105.87 250 $74.11 $52.94 $84.70 65% 80% 50% 50% 65% 65% 65% PHARMACY KETOCONAZOLE 200 MG TAB NF 1 TAB $11.06 250 $7.74 $5.53 $8.85 65% 80% 50% 50% 65% 65% 65% PHARMACY KETOCONAZOLE TOP 2% CRE 30GM 1 APP $182.42 250 $127.69 $91.21 $145.94 65% 80% 50% 50% 65% 65% 65% PHARMACY KETOROLAC 15 MG/ML INJ VL 1 ML J1885 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY KETOROLAC 30 MG/ML INJ 1ML VL 1 ML J1885 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY KETOROLAC 60 MG INJ 2 ML VL 2 ML J1885 $26.25 636 $18.38 $13.13 $21.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY KETOROLAC OPHT 0.5% SOL 3ML BTL 1 GTT $170.55 250 $119.39 $85.28 $136.44 65% 80% 50% 50% 65% 65% 65% PHARMACY KETOROLAC OPHT 0.5% SOL 3ML BTL OPHTH 1 GTT $56.85 250 $39.80 $28.43 $45.48 65% 80% 50% 50% 65% 65% 65% PHARMACY KETOROLAC OPHT 0.5% SOL 5ML BTL OPHTH 1 EA $73.85 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY KETOROLAC OPHTHALMIC 0.5% SOL 5 ML 1 GTT $74.81 250 $52.37 $37.40 $59.85 65% 80% 50% 50% 65% 65% 65% PHARMACY KETOTIFEN OPHTHALMIC 0.025% SOLN 5 ML 1 GTT $42.67 250 $29.87 $21.33 $34.13 65% 80% 50% 50% 65% 65% 65% PHARMACY LABETALOL 10 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LABETALOL 100 MG TAB NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LABETALOL 200 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LABETALOL 300 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LABETALOL 40 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LABETALOL 5 MG/ML INJ 20 ML VL 20 ML $33.60 250 $23.52 $16.80 $26.88 65% 80% 50% 50% 65% 65% 65% PHARMACY LACOSAMIDE 10 MG/ML ORAL SOLN 1 ML $8.11 250 $5.68 $4.06 $6.49 65% 80% 50% 50% 65% 65% 65% PHARMACY LACOSAMIDE 10 MG/ML(SDV) INJ 20 ML 1 ML C9254 $343.19 636 $240.23 $171.59 $274.55 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LACOSAMIDE 100 MG TAB (NF) 1 TAB $71.91 250 $50.34 $35.96 $57.53 65% 80% 50% 50% 65% 65% 65% PHARMACY LACOSAMIDE 200 MG TAB UD 1 TAB $76.19 250 $53.33 $38.09 $60.95 65% 80% 50% 50% 65% 65% 65% PHARMACY LACOSAMIDE 50 MG TAB UD 1 TAB $46.00 250 $32.20 $23.00 $36.80 65% 80% 50% 50% 65% 65% 65% PHARMACY LACTOBACILLUS ACIDOPHILUS - CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LACTOBACILLUS RHAMNOSUS GG - CAP - NF 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LACTULOSE 10 G/15 ML SYR 473 ML BTL 15 ML $4.05 250 $2.84 $2.03 $3.24 65% 80% 50% 50% 65% 65% 65% PHARMACY LACTULOSE 200 GM/300 ML ENEMA 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LACTULOSE 20GM SYRUP 30ML UD 30 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LAMIVUDINE 10 MG/ML ORAL SYG (3TC) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LAMIVUDINE 150 MG TAB (3TC) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LAMIVUDINE 150 MG TAB (NF) 1 TAB $28.58 250 $20.01 $14.29 $22.87 65% 80% 50% 50% 65% 65% 65% PHARMACY LAMIVUDINE 300 MG TAB (3TC) 1 TAB $18.76 250 $13.13 $9.38 $15.00 65% 80% 50% 50% 65% 65% 65% PHARMACY LAMOTRIGINE 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LAMOTRIGINE 150 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LAMOTRIGINE 200 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LAMOTRIGINE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LANSOPRAZOLE 3 MG/ML ORAL SUSP 1 ML $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% PHARMACY LATANOPROST OPHT 0.005% 2.5ML BTL 1 GTT $332.50 250 $232.75 $166.25 $266.00 65% 80% 50% 50% 65% 65% 65% PHARMACY LEDIPASVIR-SOFOSBUVIR 90 MG-400 MG TAB - NF 1 TAB "$4,725.00 " 250 "$3,307.50 " "$2,362.50 " "$3,780.00 " 65% 80% 50% 50% 65% 65% 65% PHARMACY LEFLUNOMIDE 10 MG TAB 1 TAB $5.51 250 $3.85 $2.75 $4.41 65% 80% 50% 50% 65% 65% 65% PHARMACY LEFLUNOMIDE 20 MG TAB - NF 1 TAB $57.42 250 $40.19 $28.71 $45.94 65% 80% 50% 50% 65% 65% 65% PHARMACY LETROZOLE 2.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEUCOVORIN 100 MG INJ (SDV) J0640 $109.81 636 $76.87 $54.91 $87.85 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUCOVORIN 25 MG TAB UD 1 TAB $22.26 250 $15.58 $11.13 $17.81 65% 80% 50% 50% 65% 65% 65% PHARMACY LEUCOVORIN 350MG INJ (SDV) J0640 $122.42 636 $85.69 $61.21 $97.93 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUCOVORIN 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEUCOVORIN 50 MG INJ (SDV) J0640 $106.67 636 $74.67 $53.33 $85.33 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUCOVORIN 500 MG INJ (SDV) J0640 $180.81 636 $126.56 $90.40 $144.64 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUPROLIDE 1 MG/0.2 ML (14 MG/2.8 ML) KIT - NF 2.8 ML J9218 "$3,118.50 " 636 "$2,182.95 " "$1,559.25 " "$2,494.80 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUPROLIDE 11.25 MG INJ KIT - GYNE 3MO J1950 "$18,688.36 " 636 "$13,081.85 " "$9,344.18 " "$14,950.68 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUPROLIDE 11.25 MG INJ KIT - PEDIATRIC 1 KIT J1950 "$13,605.20 " 636 "$9,523.64 " "$6,802.60 " "$10,884.16 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUPROLIDE 3.75 MG INJ 1 MONTH KIT - ADULT 1 KIT J1950 "$6,229.41 " 636 "$4,360.58 " "$3,114.70 " "$4,983.52 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUPROLIDE 30 MG INJ KIT 4-MONTH - ADULT 1 KIT J9217 "$29,693.16 " 636 "$20,785.21 " "$14,846.58 " "$23,754.53 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUPROLIDE 7.5 MG INJ 1 MONTH KIT - ADULT 1 KIT J9217 "$7,423.29 " 636 "$5,196.30 " "$3,711.65 " "$5,938.63 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEUPROLIDE 7.5 MG INJ KIT - PEDIATRIC 1 KIT J9217 "$7,493.99 " 636 "$5,245.79 " "$3,747.00 " "$5,995.19 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVALBUTEROL 0.31 MG/3 ML INH SOL UD (NF) 3 ML J7614 $22.51 636 $15.76 $11.26 $18.01 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVALBUTEROL 0.63 MG/3 ML INH SOL UD (NF) 3 ML J7614 $8.00 636 $5.60 $4.00 $6.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVALBUTEROL 1.25 MG/0.5 ML CONCENTRATED 1 EA J7612 $23.45 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVALBUTEROL 1.25 MG/3 ML SOL UD 3 ML J7614 $7.00 636 $4.90 $3.50 $5.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVALBUTEROL 45 MCG/INH MDI 1 INHALATION $19.11 250 $13.38 $9.55 $15.29 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVETIRACETAM 100 MG/ML (SDV) INJ 5 ML J1953 $44.10 636 $30.87 $22.05 $35.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVETIRACETAM 100 MG/ML ORAL SYRG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVETIRACETAM 250 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVETIRACETAM 500 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVETIRACETAM 750 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOCARNITINE 100 MG ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOCARNITINE 200 MG/ML INJ 1 ML J1955 $27.82 636 $19.47 $13.91 $22.26 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVOCARNITINE 330 MG TAB UD - NF 1 TAB $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOFLOXACIN 25 MG/ML ORAL SOLUTION - NF 1 ML $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOFLOXACIN 250 MG 50 ML PREMIX BAG 50 ML J1956 $25.20 636 $17.64 $12.60 $20.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVOFLOXACIN 250 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOFLOXACIN 500 MG 100ML PREMIX BAG 100 ML J1956 $25.70 636 $17.99 $12.85 $20.56 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVOFLOXACIN 500 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOFLOXACIN 750 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOFLOXACIN 750 MG/150 ML INJ PREMIX BAG 150 ML J1956 $26.21 636 $18.35 $13.10 $20.97 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVONORGESTREL 1.5 MG TAB 1 TAB $127.96 250 $89.57 $63.98 $102.37 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVONORGESTREL 13.5 MG (SKYLA) IUD DEV 1 KIT J7301 "$3,494.68 " 636 "$2,446.28 " "$1,747.34 " "$2,795.74 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVONORGESTREL 19.5 MG (KYLEENA) IUD DEV 1 KIT J7296 "$4,196.98 " 636 "$2,937.88 " "$2,098.49 " "$3,357.58 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVONORGESTREL 52 MG (LILETTA) IUD DEV 1 KIT J7297 "$3,549.42 " 636 "$2,484.59 " "$1,774.71 " "$2,839.54 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVONORGESTREL 52 MG (MIRENA) IUD DEV 1 KIT J7298 "$4,196.99 " 636 "$2,937.89 " "$2,098.50 " "$3,357.59 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVOTHYROXINE 100 MCG (0.1 MG) INJ 5 ML $443.45 250 $310.42 $221.73 $354.76 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 100 MCG (0.1 MG)/ML SOL 1 ML $314.71 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LEVOTHYROXINE 100 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 112 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 125 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 137 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 150 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 175 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 200 MCG (0.2 MG) TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 25 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 25 MCG/ML ORAL SYRG (PED) 1 ML $4.15 250 $2.91 $2.08 $3.32 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 300 MCG (0.3 MG) TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 50 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 75 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LEVOTHYROXINE 88 MCG (0.088 MG) TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCA+DEX 7.5%-5% INJ 2 ML AMP 2 ML $38.32 250 $26.83 $19.16 $30.66 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE 0.5% INJ 50ML VL 50 ML $17.47 250 $12.23 $8.74 $13.98 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE 1% INJ 10 ML VL 1 EA $10.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 1% INJ 20 ML VL 20 ML J2001 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 1% INJ 50ML VL 50 ML $11.77 250 $8.24 $5.89 $9.42 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE 1% PF (ANESTH) INJ 2ML VL 2 ML J2001 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 1% SOL 2 ML 1 ML $4.20 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 2% INJ 10 ML VL 1 ML $12.60 250 $8.82 $6.30 $10.08 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE 2% INJ 2 ML 1 EA $20.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 2% INJ 20 ML 20 ML J2001 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 2% INJ 50 ML VL 50 ML $15.46 250 $10.82 $7.73 $12.36 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE 2% PF INJ 5ML VL 5 ML J2001 $10.29 636 $7.20 $5.15 $8.23 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 2% PRESERVATIVE-FREE 10 ML 10 ML J2001 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 2% PRESERVATIVE-FREE 5ML SYR 5 ML J2001 $24.60 636 $17.22 $12.30 $19.68 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 2% PRESERVATIVE-FREE SOL 1 EA $6.15 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIDOCAINE 2% VISCOUS TOPICAL SOL 100 ML BTL 100 ML $48.13 250 $33.69 $24.06 $38.50 65% 80% 50% 50% 65% 65% 65% PHARMACY "LIDOCAINE 2% VISCOUS TOPICAL UD, 15 ML" 15 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE 2.5% + PRILOCAIN 2.5% CR 5GM/TU 1 APP $173.53 250 $121.47 $86.77 $138.82 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE OPHTHALMIC 3.5% GEL 1 APP $102.20 250 $71.54 $51.10 $81.76 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE TOPICAL 4% KIT 1 APP $115.42 250 $80.79 $57.71 $92.33 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE TOPICAL 4% SOL 50 ML BTL 1 ML $4.52 250 $3.17 $2.26 $3.62 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE TOPICAL 4% TRANSDERMAL PATCH 1 PATCH $4.95 250 $3.46 $2.47 $3.96 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE TOPICAL 5% OIN 1 APP "$1,108.31 " 250 $775.82 $554.15 $886.65 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE TOPICAL 5% TRANSDERMAL PATCH 1 PATCH $32.76 250 $22.93 $16.38 $26.21 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE TOPICAL GEL 2% W/ APPLICATOR 10 ML 1 APP $26.92 250 $18.85 $13.46 $21.54 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE UROLOGICAL 2 % GEL 30 ML BTL 1 APP $449.22 250 $314.46 $224.61 $359.38 65% 80% 50% 50% 65% 65% 65% PHARMACY LIDOCAINE VISCOUS ORAL TOPICAL 2% UD 15 ML - PREPARED BY PHARMACY 15 ML $7.22 250 $5.05 $3.61 $5.78 65% 80% 50% 50% 65% 65% 65% PHARMACY LINAGLIPTIN 5 MG TAB 1 TAB $64.73 250 $45.31 $32.36 $51.78 65% 80% 50% 50% 65% 65% 65% PHARMACY LINEZOLID 100 MG/5 ML ORAL SYG 5 ML $111.61 250 $78.13 $55.81 $89.29 65% 80% 50% 50% 65% 65% 65% PHARMACY LINEZOLID 200 MG/100 ML D5W IVPB PREMIX 100 ML J2020 $239.40 636 $167.58 $119.70 $191.52 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LINEZOLID 600 MG TAB UD 1 TAB $7.94 250 $5.55 $3.97 $6.35 65% 80% 50% 50% 65% 65% 65% PHARMACY LINEZOLID 600 MG/300 ML D5W IVPB PREMIX 300 ML J2020 $198.95 636 $139.27 $99.48 $159.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LIOTHYRONINE 25 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LIOTHYRONINE 25 MCG TAB (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LISDEXAMFETAMINE 20 MG CAP - NF 1 CAP $46.90 250 $32.83 $23.45 $37.52 65% 80% 50% 50% 65% 65% 65% PHARMACY LISDEXAMFETAMINE 30 MG CAP - NF 1 CAP $46.90 250 $32.83 $23.45 $37.52 65% 80% 50% 50% 65% 65% 65% PHARMACY LISDEXAMFETAMINE 40 MG CAP $46.90 250 $32.83 $23.45 $37.52 65% 80% 50% 50% 65% 65% 65% PHARMACY LISDEXAMFETAMINE 50 MG CAP 1 CAP $46.90 250 $32.83 $23.45 $37.52 65% 80% 50% 50% 65% 65% 65% PHARMACY LISINOPRIL 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LISINOPRIL 2.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LISINOPRIL 20 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LISINOPRIL 40 MG TAB 1 TAB $5.50 250 $3.85 $2.75 $4.40 65% 80% 50% 50% 65% 65% 65% PHARMACY LISINOPRIL 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LITHIUM 150 MG CAP UD 1 EA $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LITHIUM 300 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LITHIUM 300 MG/5 ML SYR 500 ML 5 ML $630.00 250 $441.00 $315.00 $504.00 65% 80% 50% 50% 65% 65% 65% PHARMACY LITHIUM 300 MG/5 ML SYR UD 5ML 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LITHIUM 450 MG ERT TABLET 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LOMUSTINE 10 MG CAP 1 CAP $289.77 250 $202.84 $144.89 $231.82 65% 80% 50% 50% 65% 65% 65% PHARMACY LOMUSTINE 100 MG CAP 1 CAP "$3,199.75 " 250 "$2,239.82 " "$1,599.87 " "$2,559.80 " 65% 80% 50% 50% 65% 65% 65% PHARMACY LOPERAMIDE 1 MG/7.5 ML ORAL SUSP 7.5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LOPERAMIDE 2 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LOPINAVIR-RITONAVIR 200 MG-50 MG TAB 1 TAB $17.96 250 $12.57 $8.98 $14.37 65% 80% 50% 50% 65% 65% 65% PHARMACY LOPINAVIR-RITONAVIR 400 MG-100 MG/5 ML LIQ 160 ML (NF) 5 ML "$2,150.68 " 250 "$1,505.48 " "$1,075.34 " "$1,720.54 " 65% 80% 50% 50% 65% 65% 65% PHARMACY LOPINAV-RITON 400/100MG ORAL SYG 5 ML $57.11 250 $39.98 $28.56 $45.69 65% 80% 50% 50% 65% 65% 65% PHARMACY LORATADINE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LORATADINE 5 MG/5 ML ORAL SYG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LORAZEPAM 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LORAZEPAM 2 MG/ML INJ 10 ML VL 10 ML J2060 $59.71 636 $41.80 $29.86 $47.77 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LORAZEPAM 2 MG/ML INJ 1ML 1 ML J2060 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LORAZEPAM 2 MG/ML ORAL SOLN 0.1 ML $5.60 250 $3.92 $2.80 $4.48 65% 80% 50% 50% 65% 65% 65% PHARMACY LORAZEPAM 500 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LOSARTAN 100 MG TAB 1 TAB $10.77 250 $7.54 $5.38 $8.61 65% 80% 50% 50% 65% 65% 65% PHARMACY LOSARTAN 25 MG TAB 1 TAB $5.87 250 $4.11 $2.94 $4.70 65% 80% 50% 50% 65% 65% 65% PHARMACY LOSARTAN 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY LUBIPROSTONE 8 MCG CAP - NF 1 CAP $23.38 250 $16.36 $11.69 $18.70 65% 80% 50% 50% 65% 65% 65% PHARMACY LURASIDONE 20 MG TAB - NF 1 TAB $188.50 250 $131.95 $94.25 $150.80 65% 80% 50% 50% 65% 65% 65% PHARMACY LURASIDONE 80 MG TAB - NF 1 TAB $188.50 250 $131.95 $94.25 $150.80 65% 80% 50% 50% 65% 65% 65% PHARMACY LURBINECTEDIN 4 MG INJ (SDV) - NF J9223 "$28,972.94 " 636 "$20,281.06 " "$14,486.47 " "$23,178.36 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LUSPATERCEPT 25 MG (SDV) INJ - NF J0896 "$7,899.42 " 636 "$5,529.59 " "$3,949.71 " "$6,319.53 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LUSPATERCEPT 75 MG (SDV) INJ - NF J0896 "$23,498.23 " 636 "$16,448.76 " "$11,749.12 " "$18,798.59 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY LYMPHOCYTE IMMUNE GLOBULIN ANTI-THY (EQUINE) 50 MG/ML SOL 5 ML J7504 "$1,832.25 " 636 "$1,282.58 " $916.13 "$1,465.80 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MAFENIDE TOP CM 454GM JAR 1 APP "$1,751.44 " 250 "$1,226.01 " $875.72 "$1,401.15 " 65% 80% 50% 50% 65% 65% 65% PHARMACY MAFENIDE TOPICAL 5% POW 50G 1 APP "$2,813.79 " 250 "$1,969.65 " "$1,406.90 " "$2,251.03 " 65% 80% 50% 50% 65% 65% 65% PHARMACY MAFENIDE TOPICAL 85 MG/G CRE 1 APP $268.96 250 $188.27 $134.48 $215.17 65% 80% 50% 50% 65% 65% 65% PHARMACY MAFENIDE TOPICAL CREAM 113 GM JAR 1 APP $488.64 250 $342.05 $244.32 $390.91 65% 80% 50% 50% 65% 65% 65% PHARMACY MAFENIDE TOPICAL CREAM 113.4G TUBE (NF) 1 APP $488.64 250 $342.05 $244.32 $390.91 65% 80% 50% 50% 65% 65% 65% PHARMACY MAFENIDE TOPICAL CREAM 2 OZ 1 EA $5.37 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MAGNESIUM CITRATE 17.45 G/300 ML 300 ML $4.37 250 $3.06 $2.18 $3.49 65% 80% 50% 50% 65% 65% 65% PHARMACY MAGNESIUM HYDROXIDE 8% SUSP 360ML 360 ML $8.40 250 $5.88 $4.20 $6.72 65% 80% 50% 50% 65% 65% 65% PHARMACY MAGNESIUM OXIDE 400 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MAGNESIUM SULFATE 1 GM/100 ML PREMIX 100 ML J3475 $26.84 636 $18.79 $13.42 $21.47 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MAGNESIUM SULFATE 2 GM/50ML PREMIX 50 ML J3475 $67.88 636 $47.51 $33.94 $54.30 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MAGNESIUM SULFATE 4 GM/100 ML PREMIX 100 ML J3475 $26.21 636 $18.35 $13.10 $20.97 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MAGNESIUM SULFATE 50% INJ 20 ML - FOR TPN USE 1 ML J3475 $33.05 636 $23.14 $16.53 $26.44 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MAGNESIUM SULFATE 500 MG/ML 2 ML VL 2 ML J3475 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MAGNESIUM SULFATE 500 MG/ML INJ 10 ML VL 10 ML J3475 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MANGANESE CHLORIDE 0.1 MG/ML SOL 1 ML $99.85 250 $69.90 $49.93 $79.88 65% 80% 50% 50% 65% 65% 65% PHARMACY MANGANESE SULFATE 0.1 MG/ML SOL 1 ML $103.47 250 $72.43 $51.73 $82.77 65% 80% 50% 50% 65% 65% 65% PHARMACY MANNITOL 20% INJ 500 ML BTL PREMIX 500 ML $247.54 250 $173.28 $123.77 $198.03 65% 80% 50% 50% 65% 65% 65% PHARMACY MANNITOL 25% INJ 50 ML VL 50 ML J2150 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MAP - LUSPATERCEPT 25 MG INJ - NF J0896 "$7,899.42 " 636 "$5,529.59 " "$3,949.71 " "$6,319.53 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MAP - LUSPATERCEPT 75 MG INJ - NF J0896 "$23,498.23 " 636 "$16,448.76 " "$11,749.12 " "$18,798.59 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MARAVIROC 150 MG TAB (NF) 1 TAB $41.20 250 $28.84 $20.60 $32.96 65% 80% 50% 50% 65% 65% 65% PHARMACY MARAVIROC 20 MG/ML ORAL LIQ - NF 1 ML $14.52 250 $10.17 $7.26 $11.62 65% 80% 50% 50% 65% 65% 65% PHARMACY MARAVIROC 300 MG TAB - NF 1 TAB $108.93 250 $76.25 $54.47 $87.15 65% 80% 50% 50% 65% 65% 65% PHARMACY MCT OIL ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MEASLES/MUMPS/RUBELLA/VARICELLA VIRUS VACCINE (PROQUAD) INJ 0.5 ML "$1,037.47 " 250 $726.23 $518.73 $829.97 65% 80% 50% 50% 65% 65% 65% PHARMACY MEBENDAZOLE 100 MG TAB UD (NF) 1 TAB $22.33 250 $15.63 $11.17 $17.86 65% 80% 50% 50% 65% 65% 65% PHARMACY MECLIZINE 12.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MECLIZINE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MEDROXYPROGESTERONE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MEDROXYPROGESTERONE 150 MG/ML (SDV) INJ 1 ML J1050 $144.46 636 $101.12 $72.23 $115.57 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEDROXYPROGESTERONE 2.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MEGESTROL 20 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MEGESTROL 40 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MEGESTROL 400 MG SUS 10ML BTL 10 ML $20.99 250 $14.69 $10.50 $16.79 65% 80% 50% 50% 65% 65% 65% PHARMACY MELATONIN 0.25 MG/ML ORAL LIQUID - NF 1 ML $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% PHARMACY MELATONIN 1 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MELATONIN 1 MG/ML LIQUID 1 ML $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% PHARMACY MELATONIN 3 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MELATONIN 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MELOXICAM 15 MG TAB UD - NF 1 TAB $16.96 250 $11.87 $8.48 $13.57 65% 80% 50% 50% 65% 65% 65% PHARMACY MELOXICAM 7.5 MG TAB UD - NF 1 TAB $10.84 250 $7.59 $5.42 $8.67 65% 80% 50% 50% 65% 65% 65% PHARMACY MELPHALAN 2 MG TAB 1 TAB J8600 $17.26 636 $12.08 $8.63 $13.81 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEMANTINE 10 MG TAB 1 TAB $28.00 250 $19.60 $14.00 $22.40 65% 80% 50% 50% 65% 65% 65% PHARMACY MEMANTINE 28 MG ER - NF $65.07 250 $45.55 $32.53 $52.05 65% 80% 50% 50% 65% 65% 65% PHARMACY MEMANTINE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MENINGOCOCCAL CONJ (MENACTRA) VACCINE INJ 0.5 ML 0.5 ML $565.50 250 $395.85 $282.75 $452.40 65% 80% 50% 50% 65% 65% 65% PHARMACY MENINGOCOCCAL CONJUGATE VACCINE (MENQUADFI) POLYSACCHARIDE TETANUS TOXOID GROUP ACYW INJ 1 EA 90619 "$1,310.26" 252 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MENINGOCOCCAL CONJUGATE VACCINE (MENVEO) INJ POWDER 0.5 ML $565.01 250 $395.50 $282.50 $452.00 65% 80% 50% 50% 65% 65% 65% PHARMACY "MENINGOCOCCAL GROUP B VACCINE RECOMBINANT (BEXSERO) OMV, ADJUVANTED - NF" 0.5 ML "$1,504.65 " 250 "$1,053.26 " $752.33 "$1,203.72 " 65% 80% 50% 50% 65% 65% 65% PHARMACY MEPERIDINE 50 MG/ML INJ 1ML 1 ML J2175 $10.10 636 $7.07 $5.05 $8.08 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEPIVACAINE 1% INFILT/NERVE INJ 50 ML VL 50 ML J0670 $29.19 636 $20.43 $14.60 $23.35 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEPIVACAINE 1% INJ 30 ML VL 30 ML J0670 $31.29 636 $21.90 $15.65 $25.03 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEPIVACAINE 1.5% PF (15 MG/ML) INJ 1 ML J0670 $42.42 636 $29.69 $21.21 $33.94 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEPIVACAINE 2% INFILT/NERVE INJ 50 ML VL 50 ML J0670 $45.15 636 $31.61 $22.58 $36.12 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEPIVACAINE 2% PRESERVATIVE-FREE SOL 20 ML J0670 $21.91 636 $15.34 $10.96 $17.53 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEPIVACAINE 3% INJ DENT CART 1 EA J0670 $20.00 636 $14.00 $10.00 $16.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEPIVACAINE-LEFONORDEFRIN 2% 1:20000 DENTAL INJ 1.8 ML $20.00 250 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% PHARMACY MEPOLIZUMAB 100 MG INJ - NF J2182 "$13,301.36 " 636 "$9,310.95 " "$6,650.68 " "$10,641.09 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MERCAPTOPURINE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MERCAPTOPURINE 50 MG/ML ORAL SYRG (PED) 1 ML $13.31 250 $9.32 $6.66 $10.65 65% 80% 50% 50% 65% 65% 65% PHARMACY MEROPENEM 1 GM (SDV) INJ 20 ML J2185 $840.00 636 $588.00 $420.00 $672.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEROPENEM 500 MG INJ 10 ML J2185 $420.00 636 $294.00 $210.00 $336.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MESALAMINE 250 MG ER CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MESALAMINE 4 G/60 ML ENEMA (NF) 60 ML $85.00 250 $59.50 $42.50 $68.00 65% 80% 50% 50% 65% 65% 65% PHARMACY MESALAMINE 4 GM ENEMA 60 ML 60 ML $85.00 250 $59.50 $42.50 $68.00 65% 80% 50% 50% 65% 65% 65% PHARMACY MESALAMINE 400 MG EC TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY MESALAMINE 500 MG ER 1 CAP $25.50 250 $17.85 $12.75 $20.40 65% 80% 50% 50% 65% 65% 65% PHARMACY MESNA 100 MG/ML INJ 10ML VL 10 ML J9209 $106.34 636 $74.44 $53.17 $85.07 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METFORMIN 1000 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METFORMIN 500 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METFORMIN 850 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHACHOLINE 100 MG INHALATION 1 NEB J7674 $327.60 636 $229.32 $163.80 $262.08 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHADONE 1 MG/1 ML ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHADONE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHADONE 10 MG/ML INJ - NF 1 ML J1230 "$1,633.70 " 636 "$1,143.59 " $816.85 "$1,306.96 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHADONE 10MG/ML ORAL SOLN 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHADONE 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHAZOLAMIDE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHAZOLAMIDE 50 MG TAB NF 1 TAB $26.82 250 $18.77 $13.41 $21.45 65% 80% 50% 50% 65% 65% 65% PHARMACY METHIMAZOLE 1 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHIMAZOLE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHIMAZOLE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHOCARBAMOL 750 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHOHEXITAL 500 MG INJ 50ML VL $343.70 250 $240.59 $171.85 $274.96 65% 80% 50% 50% 65% 65% 65% PHARMACY METHOTREXATE 2.5 MG TAB UD 1 TAB J8610 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHOTREXATE 25 MG/ML INJ 10ML (SDV) 10 ML J9250 $109.42 636 $76.59 $54.71 $87.53 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHOTREXATE 25 MG/ML INJ 2 ML (SDV) 2 ML J9250 $101.89 636 $71.32 $50.95 $81.51 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHOTREXATE 25 MG/ML INJ 40 ML (SDV) 40 ML J9250 $132.23 636 $92.56 $66.12 $105.78 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYL SALICY/ISOPROPANOL 480ML BTL 1 APP $9.62 250 $6.73 $4.81 $7.69 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLDOPA 25 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLDOPA 50 MG/ML INJ 5 ML VL - NF 5 ML J0210 $168.00 636 $117.60 $84.00 $134.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYLENE BLUE 5 MG/ML INJ 10 ML VL 10 ML $99.95 250 $69.96 $49.97 $79.96 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLERGONOVINE 200 MCG TAB 1 TAB $140.15 250 $98.11 $70.08 $112.12 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLERGONOVINE 200MCG INJ 1ML 1 ML J2210 $118.44 636 $82.91 $59.22 $94.75 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYLNALTREXONE 12 MG/0.6 ML SOL - NF 0.6 ML J2212 $941.62 636 $659.13 $470.81 $753.29 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYLNALTREXONE 8 MG/0.4 ML SOL 0.4 ML J2212 "$1,412.39 " 636 $988.67 $706.19 "$1,129.91 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYLPHENIDATE 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLPHENIDATE 18 MG/24 HR ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLPHENIDATE 20 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLPHENIDATE 27 MG/24 HR ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLPHENIDATE 36 MG/24 HR ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLPHENIDATE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLPHENIDATE 54 MG/24 HR ER TAB 1 TAB $58.26 250 $40.78 $29.13 $46.60 65% 80% 50% 50% 65% 65% 65% PHARMACY METHYLPRED SOD SUCC 5 MG/ML (DIL 1:12.5 NS) 1 ML J2930 $40.64 636 $28.44 $20.32 $32.51 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYLPREDNISOLONE 125 MG PF (SOLU-MEDROL) INJ 2 ML VL 2 ML J2930 $40.69 636 $28.48 $20.34 $32.55 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYLPREDNISOLONE 40 MG (SOLU-MEDROL) PF INJ 1 ML VL 1 ML J2920 $25.27 636 $17.69 $12.63 $20.21 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYLPREDNISOLONE ACETATE (DEPO-MEDROL) 40MG INJ 1 ML VL 1 ML J1030 $36.54 636 $25.58 $18.27 $29.23 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYLPREDNISOLONE ACETATE (DEPO-MEDROL) 40MG/ML INJ 5ML VL 5 ML J1030 $192.54 636 $134.77 $96.27 $154.03 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METHYLPREDNISOLONE SOD SUCC 1G INJ VL 16 ML J2930 $175.95 636 $123.16 $87.97 $140.76 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METOCLOPRAMIDE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METOCLOPRAMIDE 5 MG/5 ML ORAL SYG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METOCLOPRAMIDE 5MG/ML INJ 2ML VL 2 ML J2765 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METOLAZONE 2.5 MG TAB UD 1 TAB $7.08 250 $4.96 $3.54 $5.66 65% 80% 50% 50% 65% 65% 65% PHARMACY METOLAZONE 5 MG TAB UD 1 TAB $7.95 250 $5.57 $3.98 $6.36 65% 80% 50% 50% 65% 65% 65% PHARMACY METOPROLOL 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% 65% PHARMACY METOPROLOL 100 MG XL TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METOPROLOL 200 MG XL TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METOPROLOL 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METOPROLOL 25 MG XL TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METOPROLOL 5 MG/ 5ML INJ 5ML VL 5 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METOPROLOL 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METOPROLOL 50 MG XL TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METRONIDAZOLE 250 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METRONIDAZOLE 50 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METRONIDAZOLE 500 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METRONIDAZOLE IVPB 500 MG 100 ML PREMIX 100 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METRONIDAZOLE TOP 0.75% GEL 45GM 1 APP "$1,117.83 " 250 $782.48 $558.91 $894.26 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METRONIDAZOLE TOPICAL 0.75% CREAM 45 GM 1 APP $299.67 250 $209.77 $149.84 $239.74 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY METRONIDAZOLE VAG 0.75% GEL 70GM 1 APP $570.64 250 $399.45 $285.32 $456.51 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEXILETINE 150 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEXILETINE 200 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MEXILETINE 250 MG CAP - NF $12.24 250 $8.57 $6.12 $9.79 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MICAFUNGIN 100 MG INJ - NF J2248 $785.40 636 $549.78 $392.70 $628.32 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MICAFUNGIN 50 MG INJ - NF J2248 $392.91 636 $275.04 $196.46 $314.33 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MICONAZOLE 2% CREAM15 GM TU 1 TUBE $1.23 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MICONAZOLE 4% VAGINAL CREAM WITH APPLICATOR (3 DAY) 1 APP $4.68 250 $3.27 $2.34 $3.74 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MICONAZOLE TOP 2% CREAM TUBE 1 TUBE $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MICONAZOLE TOP 2% CREAM TUBE 15 G 1 APP $18.38 250 $12.86 $9.19 $14.70 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MICONAZOLE TOP 2% CREAM TUBE 28 G 1 APP $10.01 250 $7.01 $5.00 $8.01 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MICONAZOLE VAG 100 MG SUP (7) 1 SUPP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MICONAZOLE VAG 200 MG SUP (3) 1 SUPP $22.07 250 $15.45 $11.04 $17.66 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDAZOLAM 1 MG/ML INJ 10 ML VL 10 ML J2250 $23.94 636 $16.76 $11.97 $19.15 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDAZOLAM 1 MG/ML INJ 2 ML VL 1 EA J2250 $10.00 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDAZOLAM 1 MG/ML INJ 2 ML VL 1 ML J2250 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDAZOLAM 1 MG/ML PF INJ 2ML VL 2 ML J2250 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDAZOLAM 10 MG / 5 ML SYRUP UD 1 ML $5.13 250 $3.59 $2.57 $4.11 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDAZOLAM 5 MG/ML INJ 10 ML VL 1 ML J2250 $28.98 636 $20.29 $14.49 $23.18 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDAZOLAM 5 MG/ML PF INJ 1ML VL 1 ML J2250 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDAZOLAM 5 MG/ML PF INJ 2 ML VL FOR EMS 1 ML J2250 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDODRINE 10 MG TAB 1 TAB $5.92 250 $4.14 $2.96 $4.73 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDODRINE 2.5 MG TAB UD 1 TAB $5.01 250 $3.51 $2.50 $4.01 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIDODRINE 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIFEPRISTONE 200 MG TAB 1 TAB S0190 $315.00 636 $220.50 $157.50 $252.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MILK OF MAGNESIA SUS 30 ML UD 30 ML $8.19 250 $5.74 $4.10 $6.56 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MILRINONE 1 MG/ML (SDV) INJ 10ML 10 ML J2260 $168.00 636 $117.60 $84.00 $134.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MINERAL OIL ENEMA 133ML 1 ENEMA $7.28 250 $5.10 $3.64 $5.82 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MINERAL OIL LIGHT 100% LIQ 10ML UD - FOR EXTERNAL USE 10 ML $64.01 250 $44.81 $32.00 $51.21 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MINERAL OIL ORAL LIQ 30 ML UD 30 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MINERAL OIL/PETROLATUM/PHENYLEPHRINE TOPICAL 14%-74.9%-0.25% OIN 1 APP $25.76 250 $18.03 $12.88 $20.61 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MINOCYCLINE 100 MG (SDV) INJ 1 EA J2265 "$1,003.80" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MINOCYCLINE 100 MG CAP UD 1 CAP $4.62 250 $3.23 $2.31 $3.70 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MINOCYCLINE 50 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MINOXIDIL 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MINOXIDIL 2.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIRABEGRON 25 MG ER UD 1 TAB $58.41 250 $40.88 $29.20 $46.73 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIRTAZAPINE 15 MG ODT TAB UD 1 TAB $8.24 250 $5.77 $4.12 $6.59 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIRTAZAPINE 15 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIRTAZAPINE 30 MG ODT TAB 1 TAB $8.49 250 $5.94 $4.25 $6.79 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIRTAZAPINE 30 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIRTAZAPINE 7.5 MG TAB UD 1 TAB $9.22 250 $6.45 $4.61 $7.37 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MIRVETUXIMAB SORAVTANSINE GYNX 100 MG/20 ML SOL 1 VIAL J9063 $625.26 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MISOPROSTOL 100 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MISOPROSTOL 100 MCG TAB UD (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MISOPROSTOL 200 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MITOMYCIN 20 MG INJ (SDV) J9280 $304.14 636 $212.90 $152.07 $243.31 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MITOMYCIN 5 MG INJ (SDV) J9280 $198.67 636 $139.07 $99.34 $158.94 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MITOMYCIN OPHTHALMIC 0.2 MG KIT J7315 "$1,256.50 " 636 $879.55 $628.25 "$1,005.20 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MITOXANTRONE 2 MG/ML 12.5ML VL 12.5 ML J9293 $302.95 636 $212.07 $151.48 $242.36 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MITOXANTRONE 2 MG/ML INJ 10 ML VL 10 ML J9293 $372.69 636 $260.88 $186.35 $298.15 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MMR (MEASLES/MUMPS/RUBELLA) VACCINE INJ 0.5 ML 0.5 ML "$3,572.69 " 250 "$2,500.88 " "$1,786.34 " "$2,858.15 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MODAFINIL 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MODAFINIL 200 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MODERNA COVID-19 VACCINE 25MCG/0.25ML 6MO-11YR 1 EA 91321 $537.25 259 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MODERNA COVID-19 VACCINE 50 MCG/0.5ML 12 + YR 1 EA 91322 $542.50 260 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MOMETASONE 110 MCG/INH AER 1 INHALATION $745.05 250 $521.53 $372.52 $596.04 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MOMETASONE 220 MCG/INH AER 1 INHALATION $310.63 250 $217.44 $155.31 $248.50 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MONTELUKAST 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MONTELUKAST 5 MG CHEW TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 10 MCG/0.1ML ORAL SYR (NICU) 0.1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 10 MG/5 ML SOL UD (NF) 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 100 MG ER TAB UD - OUTPT ONLY 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 10MG SOL 5ML UD 5 ML $5.71 250 $3.99 $2.85 $4.56 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 15 MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 15 MG IR TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 2 MG/ML ORAL SYRINGE (NICU) 1 ML $43.02 250 $30.11 $21.51 $34.41 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 25 MG/ML PRESERVATIVE-FREE INJ - FOR PAIN PUMP 1 ML J2274 "$1,485.33 " 636 "$1,039.73 " $742.67 "$1,188.26 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 30 MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 30 MG IR TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 30 MG/30 ML PCA 30 ML J2270 $50.40 636 $35.28 $25.20 $40.32 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 50 MG/ML INJ 20 ML VIAL 20 ML J2270 $53.48 636 $37.44 $26.74 $42.78 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE 60 MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE INJ 0.5 MG/ML 10 ML 10 ML J2274 $28.13 636 $19.69 $14.06 $22.50 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE PF 10 MG/ML 1 ML SYR 1 ML J2270 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE PF 2 MG/ML INJ 1 ML SYG 1 ML J2270 $12.05 636 $8.44 $6.03 $9.64 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MORPHINE PF 4 MG/ML INJ 1 ML SYG 1 ML J2270 $92.05 636 $64.44 $46.03 $73.64 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MOXIFLOXACIN 400 MG TAB UD - NF 1 TAB $104.76 250 $73.33 $52.38 $83.81 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MOXIFLOXACIN 400 MG/250 ML INJ PREMIX - NF 250 ML J2280 $192.78 636 $134.95 $96.39 $154.22 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MOXIFLOXACIN OPHT 0.5% SOL - OPHTH 1 EA $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MOXIFLOXACIN OPHT 0.5% SOL 3 ML BTL 1 GTT $195.24 250 $136.67 $97.62 $156.19 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MUCOSITIS COCKTAIL ORAL SYRG 15 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MULTIVITAMIN PED ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MULTIVITAMIN PEDIATRIC MULTIPLE VITAMINS - FOR TPN USE 1 ML "$1,447.73 " 250 "$1,013.41 " $723.87 "$1,158.19 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MULTIVITAMIN THERAPEUTIC MULTIPLE VITAMINS TAB UD 1 EA $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MULTIVITAMIN VITAMIN B COMPLEX WITH C AND FOLIC ACID CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "MULTIVITAMIN W/ MINERALS (A,D,E,K-INTENSIVE) ANTIOXIDANT MVI LIQ - NF" 60 ML $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MULTIVITAMIN WITH IRON PEDIATRIC MULTIPLE VITAMINS WITH IRON LIQ 50 ML $29.96 250 $20.97 $14.98 $23.97 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "MULTIVITAMIN, PRENATAL TAB" 1 TAB S0197 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MULTIVITAMINS INJ VL - FOR TPN USE 10 ML $463.05 250 $324.14 $231.53 $370.44 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MULTIVITAMINS TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MUPIROCIN TOPICAL 2% OIN 22GM TU 1 APP $149.62 250 $104.74 $74.81 $119.70 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MUPIROCIN TOPICAL 2% OINT UD - NF 1 APP $17.94 250 $12.56 $8.97 $14.35 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MYCOPHENOLATE 50 MG/ML ORAL SYRG (PED) 1 ML J7517 $5.47 636 $3.83 $2.73 $4.38 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MYCOPHENOLATE MOFETIL 200 MG/ML ORAL SUSP - NF 1 ML J7517 $20.29 636 $14.21 $10.15 $16.23 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MYCOPHENOLATE MOFETIL 250 MG CAP UD 1 CAP J7517 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MYCOPHENOLATE MOFETIL 500 MG INJ - NF $304.50 250 $213.15 $152.25 $243.60 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MYCOPHENOLATE MOFETIL 500 MG TAB UD 1 TAB J7517 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY MYCOPHENOLIC ACID 360 MG TAB (NF) 1 TAB J7518 $47.96 636 $33.57 $23.98 $38.37 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NAFCILLIN 2 G POW 1 VIAL $64.19 250 $44.93 $32.10 $51.35 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NAFCILLIN 2 GM/ 0.9 % NACL 100 ML ADD-VANTAGE IVPB 100 ML "$9,912.35 " 250 "$6,938.65 " "$4,956.18 " "$7,929.88 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NALOXEGOL 25 MG TAB UD - NF 1 TAB $49.75 250 $34.83 $24.88 $39.80 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NALOXONE 0.4 MG/ML INJ 1 ML 1 ML J2310 $65.52 636 $45.86 $32.76 $52.41 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NALOXONE 4 MG/0.1 ML SPRAY 0.1 ML $262.50 250 $183.75 $131.25 $210.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NALOXONE INJ 1 MG/ML 2 ML 2 ML J2310 $138.60 636 $97.02 $69.30 $110.88 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NALTREXONE 380 MG INJ 1 SYRINGE J2315 "$5,944.23 " 636 "$4,160.96 " "$2,972.11 " "$4,755.38 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NALTREXONE 50 MG TAB 1 TAB $4.65 250 $3.26 $2.33 $3.72 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NAPHAZOLINE-PHENIRAMIN OPH 15ML BTL 1 GTT $31.57 250 $22.10 $15.78 $25.26 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NAPROXEN 375 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NAPROXEN 500 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NATALIZUMAB INJ 300 MG/15 ML INJ - NF 15 ML J2323 "$18,538.80 " 636 "$12,977.16 " "$9,269.40 " "$14,831.04 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NELARABINE 5 MG/ML INJ (SDV) 50 ML J9261 "$1,241.60 " 636 $869.12 $620.80 $993.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NELFINAVIR 250 MG TAB 1 TAB $6.15 250 $4.31 $3.08 $4.92 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NELFINAVIR 625 MG TAB 1 TAB $15.44 250 $10.81 $7.72 $12.35 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO/POLYB/BACI OPTH OIN - OPHTH 0.5 INCH $199.33 250 $139.53 $99.66 $159.46 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO/POLYB/BACI OPTH OIN 3.5 GM TU 0.5 INCH $199.33 250 $139.53 $99.66 $159.46 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO/POLYB/DEXA OPHT OIN - OPHTH 0.5 INCH $69.51 250 $48.66 $34.76 $55.61 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO/POLYB/DEXA OPHT OIN 3.5 GM TU 0.5 INCH $69.51 250 $48.66 $34.76 $55.61 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO/POLYB/DEXA OPHTH SOLUTION 5ML (NF) 5 ML $30.80 250 $21.56 $15.40 $24.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO/POLYB/HYDROCO OTIC SUSP 10 ML 1 GTT $367.08 250 $256.96 $183.54 $293.66 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO+POLY+GRAM OPHT - OPHTH 1 GTT $21.68 250 $15.18 $10.84 $17.34 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO+POLY+GRAM OPHT 10ML BTL 1 GTT $214.41 250 $150.09 $107.21 $171.53 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO+POLYB+DEX OPHT SUSP - OPHTH 1 EA $13.90 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEO+POLYB+DEX OPHT SUSP 5ML BTL 1 GTT $154.00 250 $107.80 $77.00 $123.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEOMYCIN 500 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEOSTIGMINE 500 MCG/ML INJ 10 ML VL 10 ML J2710 $71.40 636 $49.98 $35.70 $57.12 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEVIRAPINE 200 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NEVIRAPINE 50 MG/5 ML ORAL SYR 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIACIN 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIACIN 250 MG ER - NF 1 TAB $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIACIN 500 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NICARDIPINE 2.5 MG/ML INJ 10 ML AMP 10 ML $107.18 250 $75.03 $53.59 $85.75 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NICARDIPINE 20 MG (0.1 MG/ML) IN NACL 0.9% INJ PREMIX 200 ML $341.54 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NICARDIPINE 20 MG/NACL 0.86% 200 ML INJ PREMIX 200 ML $426.93 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NICARDIPINE 20 MG/NACL 0.86% 200 ML INJ PREMIX $441.93 250 $309.35 $220.97 $353.54 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NICOTINE 14 MG/24 HR PATCH 1 PATCH $7.50 250 $5.25 $3.75 $6.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NICOTINE 2 MG GUM 1 EA $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NICOTINE 21 MG/24 HR PATCH 1 PATCH $7.36 250 $5.15 $3.68 $5.88 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NICOTINE 7 MG/24 HR PATCH 1 PATCH $7.47 250 $5.23 $3.74 $5.98 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIFEDIPINE 10 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIFEDIPINE 30 MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIFEDIPINE 60MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIFEDIPINE 90 MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NILOTINIB 200 MG CAP 1 CAP $590.48 250 $413.33 $295.24 $472.38 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIMODIPINE 30 MG CAP UD 1 CAP $6.70 250 $4.69 $3.35 $5.36 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIRSEVIMAB (CVX 306) ALIP PRESERVATIVE-FREE 50 MG/0.5 ML SOL 0.5 ML 90380 "$4,158.00" 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIRSEVIMAB (CVX 307) ALIP PRESERVATIVE-FREE 100 MG/ML SOL 1 ML 90381 "$2,079.00" 251 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITAZOXANIDE 500 MG TAB - NF 1 TAB $565.46 250 $395.82 $282.73 $452.37 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROFURANTOIN 25 MG/5 ML ORAL SYG 5 ML $218.05 250 $152.64 $109.03 $174.44 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROFURANTOIN MACRO 100 MG CAP 1 CAP $5.83 250 $4.08 $2.91 $4.66 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROFURANTOIN MACROCRYSTALS-MONOHYDRATE 100 MG CAP UD 1 CAP $13.18 250 $9.23 $6.59 $10.54 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN 0.4 MG TAB #25 SL TABS BTL 1 TAB $5.76 250 $4.03 $2.88 $4.61 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN 2% OIN 60GM 1 INCH $298.13 250 $208.69 $149.07 $238.50 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN 2% OINT 1GM/PKT (= 1 INCH) 1 INCH $9.64 250 $6.75 $4.82 $7.71 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN 200 MCG/HR PATCH 1 PATCH $6.66 250 $4.66 $3.33 $5.33 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN 400 MCG TAB 1 TAB $5.76 250 $4.03 $2.88 $4.61 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN 400 MCG/HR PATCH 1 PATCH $7.60 250 $5.32 $3.80 $6.08 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN 5 MG/ML INJ 10 ML VL 10 ML $59.93 250 $41.95 $29.97 $47.95 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN 600 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN 600 MCG/HR PATCH 1 PATCH $8.39 250 $5.87 $4.19 $6.71 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NITROGLYCERIN D5W 25 MG/250 ML (100MCG/ML) FOR CATH LAB PREMIX $78.93 250 $55.25 $39.47 $63.15 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "NITROPRUSSIDE 25 MG/ML, 2 ML VL" 1 ML $336.00 250 $235.20 $168.00 $268.80 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIVOLUMAB 10 MG/ML INJ 10ML (SDV) 10 ML J9299 "$4,741.36 " 636 "$3,318.95 " "$2,370.68 " "$3,793.09 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIVOLUMAB 10 MG/ML INJ 24 ML (SDV) 24 ML J9299 "$10,273.42 " 636 "$7,191.39 " "$5,136.71 " "$8,218.73 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NIVOLUMAB 10 MG/ML INJ 4ML (SDV) 4 ML J9299 "$1,947.71 " 636 "$1,363.40 " $973.86 "$1,558.17 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NOREPINEPHRINE 1 MG/ML INJ 4 ML 4 ML $91.38 250 $63.97 $45.69 $73.11 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NORETHINDRONE 5 MG TAB 1 TAB $9.27 250 $6.49 $4.64 $7.42 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NORTRIPTYLINE 25 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NORTRIPTYLINE 50 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NOVAVAX COVID -19 VACCINE 50 MCG/0.5 ML 12+YR 1 EA 91304 $546.00 255 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "NYSTATIN 100,000 UNITS/G PWD 15GM" $96.11 250 $67.28 $48.06 $76.89 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NYSTATIN 100000 UNITS/ML ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NYSTATIN 500000 UNITS/5 ML SUS UD 5 ML $5.39 250 $3.77 $2.69 $4.31 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NYSTATIN OIN 15GM TU 1 APP $61.25 250 $42.88 $30.63 $49.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NYSTATIN TOP CRE 15GM TU 1 APP $61.25 250 $42.88 $30.63 $49.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NYSTATIN TOPICAL 100000 UNITS/G CREAM 30 GM 1 APP $92.16 250 $64.51 $46.08 $73.72 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NYSTATIN-TRIAMC TOP OIN 60GM 1 APP $795.55 250 $556.88 $397.77 $636.44 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NYSTATIN-TRIAMCINOLONE TOP CRE 30GM 1 APP $558.32 250 $390.82 $279.16 $446.66 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY NYSTATIN-TRIAMCINOLONE TOPICAL TOP OINT 30 GM 1 APP $558.32 250 $390.82 $279.16 $446.66 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OBINUTUZUMAB 1000 MG/ 40 ML INJ 40 ML J9301 $687.86 636 $481.50 $343.93 $550.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCRELIZUMAB 30 MG/ML (SDV) INJ - NF 10 ML J2350 "$7,152.77 " 636 "$5,006.94 " "$3,576.39 " "$5,722.22 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCTREOTIDE 10 MG INJ VL DEPOT J2353 "$10,808.20 " 636 "$7,565.74 " "$5,404.10 " "$8,646.56 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCTREOTIDE 100 MCG (SDV) INJ 1 ML 1 VIAL J2354 $41.75 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCTREOTIDE 100 MCG INJ 1 ML AMP 1 ML J2354 $41.75 636 $29.22 $20.87 $33.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCTREOTIDE 20 MG INJ VL DEPOT 1 VIAL J2353 "$18,635.58" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCTREOTIDE 20 MG INJ VL DEPOT J2353 "$17,911.92 " 636 "$12,538.34 " "$8,955.96 " "$14,329.53 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCTREOTIDE 30 MG INJ VL DEPOT J2353 "$26,821.80 " 636 "$18,775.26 " "$13,410.90 " "$21,457.44 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCTREOTIDE 50 MCG (SDV) INJ 1 ML 1 ML J2354 $18.90 636 $13.23 $9.45 $15.12 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCTREOTIDE 500 MCG (SDV) INJ 1 ML 1 ML J2354 $208.70 636 $146.09 $104.35 $166.96 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCULAR LUBRICANT - SOL 1 BTL $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCULAR LUBRICANT (GENTEAL) GEL - NF 1 APP $25.72 250 $18.00 $12.86 $20.57 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCULAR LUBRICANT OINT 3.5 GM TUBE 0.5 INCH $71.01 250 $49.71 $35.51 $56.81 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCULAR LUBRICANT PF SOLUTION UD 1 GTT $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCULAR LUBRICANT PRESERVED - OPHTH 1 EA $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCULAR LUBRICANT PRESERVED 15 ML BTL 1 GTT $9.91 250 $6.93 $4.95 $7.92 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OCULAR LUBRICANT PRESERVED SOLN REWETTING DROPS 1 GTT $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OFATUMUMAB 20 MG/ML 100 MG INJL - NF 5 ML J9302 "$2,534.15 " 636 "$1,773.91 " "$1,267.08 " "$2,027.32 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OFATUMUMAB 20 MG/ML 1000 MG SOL - NF 50 ML J9302 "$7,652.53 " 636 "$5,356.77 " "$3,826.27 " "$6,122.03 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OFLOXACIN OPHTHALMIC 0.3% SOLN 5 ML BTL 1 GTT $246.23 250 $172.36 $123.11 $196.98 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OFLOXACIN OTIC 0.3% SOLN 5 ML 1 GTT $108.00 250 $75.60 $54.00 $86.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OLANZAPINE 10 MG INJ 1 VIAL $145.25 250 $101.68 $72.63 $116.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OLANZAPINE 10 MG TAB (ODT) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OLANZAPINE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OLANZAPINE 15 MG TAB UD 1 TAB $28.63 250 $20.04 $14.32 $22.91 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OLANZAPINE 2.5 MG TAB 1 TAB $39.19 250 $27.43 $19.60 $31.35 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OLANZAPINE 5 MG TAB (ODT) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OLANZAPINE 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OLANZAPINE 7.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OLODATEROL 2.5 MCG/INH MDI INHALER 1 INHALATION $235.77 250 $165.04 $117.88 $188.62 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OMALIZUMAB 150 MG (SDV) INJ - NF 1.2 ML J2357 "$4,646.71 " 636 "$3,252.69 " "$2,323.35 " "$3,717.36 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OMALIZUMAB 75 MG/0.5 ML (SDV) INJ - NF 0.5 ML J2357 "$4,646.74 " 636 "$3,252.72 " "$2,323.37 " "$3,717.39 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OMEGA-3 ACIDS ETHYL ESTERS 1000 MG 1 CAP $12.77 250 $8.94 $6.39 $10.22 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OMEGA-3 POLYUNSATURATED FATTY ACIDS 1000 MG CAP 1 EA $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OMEPRAZOLE 2 MG/ML SUS - NF 1 ML $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONABOTULINUMTOXINA 100 UNITS INJ 1 VIAL J0585 "$2,524.20 " 636 "$1,766.94 " "$1,262.10 " "$2,019.36 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONABOTULINUMTOXINA 100 UNITS INJ - OPHTH 1 EA "$2,210.73 " 250 "$1,547.51 " "$1,105.36 " "$1,768.58 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONABOTULINUMTOXINA 200 UNITS INJ 1 VIAL J0585 "$4,410.00 " 636 "$3,087.00 " "$2,205.00 " "$3,528.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONDANSETRON 16 MG/100 ML NS PREMADE 100 ML J2405 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONDANSETRON 2 MG/ML INJ 20 ML VL 1 ML J2405 $21.07 636 $14.75 $10.54 $16.86 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONDANSETRON 4 MG ODT TAB UD 1 TAB Q0162 $77.99 636 $54.59 $39.00 $62.39 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONDANSETRON 4 MG TAB (NF) 1 TAB Q0162 $82.71 636 $57.90 $41.35 $66.17 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONDANSETRON 8 MG ODT TAB 1 TAB Q0162 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONDANSETRON 8 MG TAB (NF) 1 TAB Q0162 $137.77 636 $96.44 $68.88 $110.21 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONDANSETRON 8 MG/50 ML NS PREMADE 50 ML J2405 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ONDANSETRON INJ 4 MG/ 2 ML 2 ML J2405 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OPHTHALMIC IRRIGATION SOL 30ML BTL 1 GTT $79.17 250 $55.42 $39.59 $63.34 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ORITAVANCIN 400 MG VL - NF J2407 "$4,060.00 " 636 "$2,842.00 " "$2,030.00 " "$3,248.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OSELTAMIVIR 30 MG CAP 1 CAP $49.63 250 $34.74 $24.82 $39.70 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OSELTAMIVIR 6 MG/ML ORAL SUSP 1 EA $9.57 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OSELTAMIVIR 6 MG/ML POW 1 ML $9.57 250 $6.70 $4.78 $7.65 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OSELTAMIVIR 6MG/ML ORAL SYRG 12.5 ML $633.15 250 $443.21 $316.58 $506.52 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OSELTAMIVIR 75 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OSELTAMIVIR 75 MG CAP 10 CAPSULE BOX 1 CAP $54.10 250 $37.87 $27.05 $43.28 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXACILLIN 1 GM INJ VL 10 ML J2700 $507.50 636 $355.25 $253.75 $406.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXACILLIN 1 GM/100 ML D5W PREMADE KIT 100 ML J2700 $50.75 636 $35.53 $25.38 $40.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXACILLIN 2 GM INJ VL 20 ML J2700 "$1,015.00 " 636 $710.50 $507.50 $812.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXACILLIN 2 GM/100 ML D5W PREMADE KIT 100 ML J2700 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXACILLIN 40 MG/ML (DIL 1:2.5 D5W) 1 ML J2700 $50.75 636 $35.53 $25.38 $40.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXALIPLATIN 5 MG/ML INJ 10 ML (SDV) 10 ML J9263 $104.25 636 $72.97 $52.12 $83.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXALIPLATIN 5 MG/ML INJ 20 ML (SDV) 20 ML J9263 $100.42 636 $70.29 $50.21 $80.33 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXANDROLONE 10 MG TAB 1 TAB $65.63 250 $45.94 $32.81 $52.50 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXCARBAZEPINE 150 MG TAB UD 1 TAB $5.28 250 $3.70 $2.64 $4.22 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXCARBAZEPINE 300 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXCARBAZEPINE 300 MG/5 ML SUSP 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXCARBAZEPINE 600 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXYBUTYNIN 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXYCODONE 10 MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXYCODONE 20 MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXYCODONE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXYMETAZOLINE NASAL 0.05% 30 ML 1 SPRAY $10.32 250 $7.23 $5.16 $8.26 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXYMETAZOLINE NASAL 0.05% SPR 15ML 1 SPRAY $17.60 250 $12.32 $8.80 $14.08 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXYTOCIN 10 UNITS / ML INJ 1ML VL 1 ML J2590 $12.60 636 $8.82 $6.30 $10.08 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXYTOCIN 10 UNITS/ML INJ 1ML VL 1 ML J2590 $14.49 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY OXYTOCIN 30 UNITS/NS 500 ML PREMIX 500 ML J2590 $175.00 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PACLITAXEL (TAXOL) 30 MG/5 ML INJ 16.7 ML VL 16.7 ML J9267 $131.88 636 $92.31 $65.94 $105.50 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PACLITAXEL (TAXOL) 30 MG/5 ML INJ 5 ML VL 5 ML J9267 $114.48 636 $80.13 $57.24 $91.58 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PACLITAXEL (TAXOL) 30 MG/5 ML INJ 50 ML VL 50 ML J9267 $168.09 636 $117.66 $84.05 $134.47 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PACLITAXEL PROTEIN-BOUND (ABRAXANE) INJ (SDV) 20 ML J9264 "$6,350.47 " 636 "$4,445.33 " "$3,175.24 " "$5,080.38 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIPERIDONE 1.5 MG ER TAB - NF 1 TAB $106.97 250 $74.88 $53.48 $85.57 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIPERIDONE 117 MG/0.75 ML SUS - NF 0.75 ML J2426 "$8,231.91 " 636 "$5,762.33 " "$4,115.95 " "$6,585.53 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIPERIDONE 156 MG/ML SUS - NF 1 ML J2426 "$8,232.21 " 636 "$5,762.55 " "$4,116.11 " "$6,585.77 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIPERIDONE 234 MG/1.5 ML SUS - NF 1.5 ML J2426 "$8,232.02 " 636 "$5,762.42 " "$4,116.01 " "$6,585.62 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIPERIDONE 3 MG ER TAB 1 TAB $51.50 250 $36.05 $25.75 $41.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIPERIDONE 39 MG/0.25 ML SUS - NF 0.25 ML J2426 "$8,231.44 " 636 "$5,762.01 " "$4,115.72 " "$6,585.15 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIPERIDONE 6 MG ER TAB - NF 1 TAB $46.25 250 $32.37 $23.12 $37.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIPERIDONE 78 MG/0.5 ML SUS - NF 0.5 ML J2426 "$8,231.72 " 636 "$5,762.20 " "$4,115.86 " "$6,585.38 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIPERIDONE 9 MG ER - NF 1 TAB $69.37 250 $48.56 $34.69 $55.50 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PALIVIZUMAB 50 MG/ 0.5 ML INJ VL 0.5 ML "$13,677.58 " 250 "$9,574.31 " "$6,838.79 " "$10,942.06 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PAMIDRONATE 30 MG INJ 10ML VL 10 ML J2430 $60.73 636 $42.51 $30.36 $48.58 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PAMIDRONATE 9 MG/ML INJ, 10ML VL" 10 ML J2430 $150.57 636 $105.40 $75.29 $120.46 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PANCRELIPASE 10,500 UNITS-61,500 UNITS-35,500 UNITS DRC" 1 CAP $12.61 250 $8.83 $6.31 $10.09 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PANCRELIPASE 24,000/76,000/120,000 UNITS DRC" 1 CAP $29.53 250 $20.67 $14.77 $23.63 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PANCRELIPASE 25,000 UNITS-79,000 UNITS-105,000 UNITS DRC - NF" 1 CAP $38.38 250 $26.87 $19.19 $30.70 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PANCRELIPASE 36,000/114,000/180,000 UNITS DRC" 1 CAP $44.84 250 $31.39 $22.42 $35.87 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PANCRELIPASE 5000 UNITS-17,000 UNITS-24,000 UNITS DRC" 1 CAP $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PANCRELIPASE 6000/19,000/30,000 UNITS DRC" 1 CAP $7.45 250 $5.22 $3.73 $5.96 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PANITUMUMAB 20 MG/ML 100MG (SDV) INJ - NF 5 ML J9303 "$1,141.30 " 636 $798.91 $570.65 $913.04 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PANITUMUMAB 20 MG/ML 400 MG (SDV) INJ - NF 20 ML J9303 "$1,141.30 " 636 $798.91 $570.65 $913.04 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PANTOPRAZOLE 2 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PANTOPRAZOLE 20 MG TAB 1 TAB $13.30 250 $9.31 $6.65 $10.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PANTOPRAZOLE 40 MG DR TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PANTOPRAZOLE INJ 40 MG (SDV) INJ 10 ML S0164 $273.00 636 $191.10 $136.50 $218.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PAPAVERINE 30 MG/ML INJ 2ML VL 2 ML J2440 $173.92 636 $121.75 $86.96 $139.14 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PARICALCITOL 2 MCG CAP 1 CAP $109.29 250 $76.50 $54.64 $87.43 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PARICALCITOL 2 MCG/ML SOL (NF) 1 ML J2501 $25.45 636 $17.82 $12.73 $20.36 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PAROMOMYCIN 250 MG CAP 1 CAP $5.33 250 $3.73 $2.67 $4.27 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PAROXETINE 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PAROXETINE 20 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PAROXETINE 30 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PAROXETINE 40 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PASIREOTIDE 20 MG LAR INJ - NF J2502 "$58,410.24 " 636 "$40,887.17 " "$29,205.12 " "$46,728.19 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PASIREOTIDE 40 MG LAR INJ - NF J2502 "$58,410.24 " 636 "$40,887.17 " "$29,205.12 " "$46,728.19 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PASIREOTIDE 60 MG LAR INJ - NF J2502 "$58,410.24 " 636 "$40,887.17 " "$29,205.12 " "$46,728.19 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PCV13 (PNEUMOCOCCAL 13-VALENT) VACCINE INJ 0.5 ML 0.5 ML "$1,778.61 " 250 "$1,245.03 " $889.30 "$1,422.89 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PCV20 (PNEUMOCOCCAL 20-VALENT) CONJUGATE VACCINE INJ 0.5 ML 1 EA 90677 "$2,127.00" 253 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PEGASPARGASE 750 INTL UNITS/ML INJ (SDV) 5 ML J9266 $100.11 636 $70.08 $50.06 $80.09 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PEGFILGRASTIM 6 MG/0.6 ML INJ - NF 0.6 ML J2506 "$44,925.94 " 636 "$31,448.16 " "$22,462.97 " "$35,940.75 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PEGINTERFERON ALFA-2A 180 MCG/ML SOL 1 ML S0145 "$4,290.27" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PEMBROLIZUMAB 25 MG/ML INJ (SDV) 4 ML J9271 "$8,316.58 " 636 "$5,821.61 " "$4,158.29 " "$6,653.27 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PEMETREXED 100 MG INJ (SDV) 1 ML J9305 $931.03 636 $651.72 $465.51 $744.82 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PEMETREXED 500 MG INJ (SDV) 20 ML J9305 "$3,951.52 " 636 "$2,766.06 " "$1,975.76 " "$3,161.21 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLAMINE 250 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN G BEN 0.6 MILLION_UNITS / ML 1ML SYR 1 ML J0561 $417.48 636 $292.24 $208.74 $333.99 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN G BEN 1.2 MILLION_UNITS / 2 ML INJ SYR 2 ML J0561 $723.07 636 $506.15 $361.53 $578.45 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN G BENZATHINE 2.4 MILLION_UNITS / 4 ML INJ 4 ML J0561 $370.42 636 $259.29 $185.21 $296.34 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PENICILLIN G POTASS 100,000 UNITS/ML (DIL 1:5 SWFI)" 1 ML J2540 $10.61 636 $7.42 $5.30 $8.48 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PENICILLIN G POTASSIUM 1:10,000 DILUTION FOR SKIN TESTING" J2540 $213.71 636 $149.60 $106.86 $170.97 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN G POTASSIUM 20 MILLION_UNITS INJ VL 40 ML J2540 $213.71 636 $149.60 $106.86 $170.97 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN G POTASSIUM 3 MILLION_UNITS D5W 50 ML PREMADE 1 BAG J2540 $10.00 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN G POTASSIUM 5 MILLION_UNITS D5W 100 ML PREMADE 100 ML J2540 $53.15 636 $37.20 $26.57 $42.52 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN V POTASSIUM 250 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN V POTASSIUM 250 MG TAB (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SYR 5 ML $51.80 250 $36.26 $25.90 $41.44 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN V POTASSIUM 250 MG/5 ML PWD 200 ML BTL 10 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENICILLIN V POTASSIUM 500 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENTAFLUOROPROPANE-TETRAFLUOROETHANE TOPICAL - SPRAY 1 SPRAY $115.50 250 $80.85 $57.75 $92.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENTAMIDINE 3 MG/ML (DIL 1:20 D5W) 1 ML J2545 $31.97 636 $22.38 $15.99 $25.58 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENTAMIDINE 300 MG INH VL 1 INHALATION J2545 $700.95 636 $490.66 $350.47 $560.76 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENTAMIDINE 300 MG INJ VL "$4,103.40 " 250 "$2,872.38 " "$2,051.70 " "$3,282.72 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENTOBARBITAL 5 MG/ML (DIL 1:10 D5W) 1 ML J2515 $144.16 636 $100.91 $72.08 $115.33 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENTOSAN POLYSULFATE SODIUM 100 MG CAP - NF 1 CAP $40.25 250 $28.18 $20.13 $32.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENTOSTATIN 10 MG INJ 5 ML J9268 "$9,312.84 " 636 "$6,518.98 " "$4,656.42 " "$7,450.27 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PENTOXIFYLLINE 400 MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PERAMIVIR 200MG/20ML INJ 1 ML J2547 "$1,330.00 " 636 $931.00 $665.00 "$1,064.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PERMETHRIN TOP 5% CRE 60GM TU 1 APP $415.80 250 $291.06 $207.90 $332.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PERMETHRIN TOPICAL 1% LOT 60 ML 1 APP $22.38 250 $15.66 $11.19 $17.90 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PEROXIDE WATER ORAL RINSE 15 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PERPHENAZINE 2 MG TAB 1 TAB Q0175 $6.11 636 $4.28 $3.05 $4.89 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PERPHENAZINE 4 MG TAB 1 TAB Q0175 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PERTUZUMAB 420 MG/14 ML INJ (SDV) 14 ML J9306 "$7,276.54 " 636 "$5,093.58 " "$3,638.27 " "$5,821.24 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PETROLATUM 43% (ALOE VESTA) OINT - NF 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PETROLATUM MINERAL OIL OPHTH - OIN 3.5 GM TU 0.5 INCH $17.36 250 $12.15 $8.68 $13.89 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PETROLATUM TOPICAL 30GM TU 1 APP $9.93 250 $6.95 $4.96 $7.94 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PETROLATUM TOPICAL 100% OINT 1 OZ (NF) 1 APP $9.93 250 $6.95 $4.96 $7.94 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PETROLATUM WHITE 368 GM JAR 1 APP $11.03 250 $7.72 $5.51 $8.82 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PETROLATUM/MINERAL OIL/WAX (EUCERIN) 454GM 1 APP $16.80 250 $11.76 $8.40 $13.44 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PFIZER COVID-19 VACCINE 10MCG/0.3ML 5-11YR 1 EA 91319 $323.40 257 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PFIZER COVID-19 VACCINE 30 MCG/0.3ML 12+ YR 1 EA 91320 $483.00 258 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PFIZER COVID-19 VACCINE 3MCG/0.3ML 6MO-4 YR 1 EA 91318 $241.50 256 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENAZOPYRIDINE 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENAZOPYRIDINE 200 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENOBARB 130 MG INJ 1ML SYG 1 ML J2560 $237.85 636 $166.49 $118.92 $190.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENOBARB 4MG/ML ELIX ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENOBARBITAL 15 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENOBARBITAL 32.4 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENOBARBITAL 65 MG/ML INJ 1 ML J2560 $100.72 636 $70.50 $50.36 $80.57 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENOL TOPICAL 6% COMPOUND FOR PAIN CLINIC 1 ML $73.08 250 $51.16 $36.54 $58.46 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENOXYBENZAMINE 10 MG CAP 1 CAP $68.25 250 $47.78 $34.13 $54.60 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENTOLAMINE 5 MG INJ 2ML VL J2760 "$1,872.43 " 636 "$1,310.70 " $936.22 "$1,497.94 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYLEPHRINE 10 MG/ML INJ 1 ML VL 1 ML J2370 $13.44 636 $9.41 $6.72 $10.75 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYLEPHRINE 10 MG/ML INJ 5 ML VL 5 ML J2370 $24.84 636 $17.39 $12.42 $19.87 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYLEPHRINE NASAL 0.25% SPRAY 1 SPRAY $13.30 250 $9.31 $6.65 $10.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYLEPHRINE NASAL 0.5% GTTS 15ML BTL 1 SPRAY $13.30 250 $9.31 $6.65 $10.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYLEPHRINE NASAL 1% SPR 30ML 1 SPRAY $7.59 250 $5.32 $3.80 $6.08 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYLEPHRINE NASAL 1% SPRAY 15 ML (NF) 2 SPRAY $14.95 250 $10.46 $7.47 $11.96 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYLEPHRINE OPH 10% SOL 5ML BTL 1 GTT $168.00 250 $117.60 $84.00 $134.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYLEPHRINE OPH 2.5% SOL 2ML BTL 1 GTT $142.21 250 $99.54 $71.10 $113.76 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYLEPHRINE OPHTHALMIC 2.5% SOL - OPHTH 1 GTT $71.10 250 $49.77 $35.55 $56.88 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PHENYLEPHRINE OPHTHALMIC 2.5% SOL, 15 ML" 1 GTT $26.25 250 $18.38 $13.13 $21.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYTOIN 100 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYTOIN 100 MG INJ 2 ML AMP 2 ML J1165 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYTOIN 125 MG/5 ML 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYTOIN 125 MG/5 ML ORAL SYG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYTOIN 25 MG/ML SUS UD 4 ML 4 ML $7.56 250 $5.29 $3.78 $6.05 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYTOIN 250 MG INJ 5 ML AMP 5 ML J1165 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYTOIN 30 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHENYTOIN 50 MG CHEW TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHYSOSTIGMINE 1 MG/ML INJ 2 ML AMP 1 ML $328.80 250 $230.16 $164.40 $263.04 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJ 0.5 ML J3430 $17.85 636 $12.50 $8.93 $14.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHYTONADIONE 10 MG INJ 1 ML VL 1 ML J3430 $179.62 636 $125.73 $89.81 $143.70 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHYTONADIONE 1MG/ML ORAL SYRG (PED) 1 ML $115.43 250 $80.80 $57.71 $92.34 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PHYTONADIONE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PILOCARPINE 5 MG TAB 1 TAB $4.92 250 $3.45 $2.46 $3.94 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PILOCARPINE 5 MG TAB (NF) 1 TAB $5.66 250 $3.96 $2.83 $4.53 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PILOCARPINE OPHT 1% SOL - OPHTH 1 GTT $9.52 250 $6.66 $4.76 $7.62 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PILOCARPINE OPHT 1% SOL 15ML BTL 1 GTT $344.96 250 $241.47 $172.48 $275.97 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PILOCARPINE OPHT 2% SOL 15ML BTL 1 GTT $339.40 250 $237.58 $169.70 $271.52 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PILOCARPINE OPHT 4% SOL - OPHTH 1 GTT $10.27 250 $7.19 $5.13 $8.21 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PILOCARPINE OPHT 4% SOL 15ML BTL 1 GTT $369.92 250 $258.94 $184.96 $295.93 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIMECROLIMUS TOPICAL 1% CREAM 60 GM 1 APP "$2,512.06 " 250 "$1,758.44 " "$1,256.03 " "$2,009.64 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIMOZIDE 1 MG TAB - NF 1 TAB $6.40 250 $4.48 $3.20 $5.12 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIMOZIDE 2 MG TAB - NF 1 TAB $8.54 250 $5.98 $4.27 $6.83 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIOGLITAZONE 15 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIOGLITAZONE 15 MG UD NF 1 TAB $19.89 250 $13.92 $9.94 $15.91 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIOGLITAZONE 30 MG TAB 1 TAB $30.39 250 $21.28 $15.20 $24.31 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIOGLITAZONE 45 MG TAB 1 TAB $40.66 250 $28.46 $20.33 $32.53 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIPERACILLIN 3000 MG / TAZO 375 MG (SDV) INJ J2543 $216.30 636 $151.41 $108.15 $173.04 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIPERACILLIN 4 G-TAZOBACTAM 0.5 G INJ VL 1 VIAL J2543 $28.56 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIPERACILLIN 4 G-TAZOBACTAM 0.5 G INJ VL - NF J2543 $444.36 636 $311.05 $222.18 $355.49 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIPERACILLIN-TAZO 3.375 GM/100 ML D5W IVPB PREMADE KIT 100 ML J2543 $450.45 636 $315.32 $225.23 $360.36 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIPERACILLIN-TAZO 60 MG/ML (DIL 1:3.33 D5W) 1 ML J2543 $65.24 636 $45.67 $32.62 $52.19 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PIROXICAM 20 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PODOFILOX TOPICAL 0.5% GEL 4GM TU 1 APP "$2,315.80 " 250 "$1,621.06 " "$1,157.90 " "$1,852.64 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PODOPHYLLUM RESIN TOPICAL 25% SOLN 15 ML 15 ML $428.75 250 $300.13 $214.38 $343.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POLATUZUMAB-PIIQ VEDOTIN 140 MG INJ 1 EA J9309 "$26,492.08" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POLATUZUMAB-PIIQ VEDOTIN 30 MG INJ 1 EA J9309 "$5,755.45" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POLYETHYLENE GLYCOL 3350 - POWDER PKT 1 PKT $6.59 250 $4.61 $3.30 $5.27 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POLYMYXIN B-TRIMETHOPRIM OPHTHALMIC 10000 UNITS-1 MG/ML SOL 1 GTT $6.10 250 $4.27 $3.05 $4.88 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PONATINIB 45 MG TAB - NF 1 TAB "$2,318.54 " 250 "$1,622.98 " "$1,159.27 " "$1,854.83 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PORACTANT 80 MG/ML SUS, 1.5ML VL" 1.5 ML "$2,074.31 " 250 "$1,452.02 " "$1,037.16 " "$1,659.45 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PORACTANT 80 MG/ML SUS, 3ML VL" 3 ML "$4,090.31 " 250 "$2,863.22 " "$2,045.15 " "$3,272.25 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POSACONAZOLE 100 MG TAB - NF 1 TAB $198.10 250 $138.67 $99.05 $158.48 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POSACONAZOLE 18 MG/ML INJ - NF 1 ML "$2,227.89 " 250 "$1,559.52 " "$1,113.95 " "$1,782.31 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POSACONAZOLE 40 MG/ML SUS - NF 1 ML $57.58 250 $40.31 $28.79 $46.07 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM ACETATE 2 MEQ/ML 20 ML VL 20 ML $14.35 250 $10.05 $7.18 $11.48 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM ACETATE 2 MEQ/ML 50 ML VL - FOR TPN USE 1 ML $44.32 250 $31.02 $22.16 $35.46 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM ACETATE 4 MEQ/ML 50 ML VL 1 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM CHLORIDE 1.33 MEQ/1 ML ORAL SYG 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM CHLORIDE 20 MEQ ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM CHLORIDE 2MEQ/ML INJ VL 1 ML J3480 $19.07 636 $13.35 $9.54 $15.26 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM CITRATE 10 MEQ ER 1 TAB $10.13 250 $7.09 $5.06 $8.10 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM CL 10 MEQ ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM CL 20 MEQ LIQ 15 ML UD 15 ML $73.11 250 $51.18 $36.55 $58.49 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM CL 20MEQ INJ 100 ML PREMIX BAG 100 ML J3480 $15.73 636 $11.01 $7.87 $12.59 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM IODIDE SOL 30ML BTL 1 GTT "$1,653.75 " 250 "$1,157.63 " $826.88 "$1,323.00 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM PHOSPHATE 3 MMOL/ML SOL 15 ML 15 ML $61.50 250 $43.05 $30.75 $49.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM PHOSPHATE 500 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POTASSIUM PHOS-SODIUM PHOS 250 MG 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POVIDONE IODINE 10% SOL 240ML BTL 1 APP $11.34 250 $7.94 $5.67 $9.07 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POVIDONE IODINE 10% SWAB 50 BOX 1 SWAB $26.64 250 $18.64 $13.32 $21.31 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POVIDONE IODINE 5% OPHTHALMIC DROPS 1 GTT $53.97 250 $37.78 $26.99 $43.18 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY POVIDONE IODINE TOPICAL 10% SOL 1 APP $5.21 250 $3.65 $2.61 $4.17 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PPSV23 (PNEUMOCOCCAL 23-POLYVALENT) VACCINE INJ 0.5 ML 0.5 ML $491.74 250 $344.22 $245.87 $393.39 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRALATREXATE 20 MG/ML SOL - NF 2 ML J9307 "$11,242.74 " 636 "$7,869.92 " "$5,621.37 " "$8,994.19 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRALIDOXIME 1 GM INJ VL J2730 "$2,184.84 " 636 "$1,529.39 " "$1,092.42 " "$1,747.87 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAMIPEXOLE 1 MG TAB 1 TAB $4.11 250 $2.87 $2.05 $3.29 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAMIPEXOLE 125 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAMIPEXOLE 250 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAMIPEXOLE 500 MCG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRASUGREL 10 MG TAB UD 1 TAB $57.77 250 $40.44 $28.88 $46.22 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRASUGREL 5 MG TAB UD 1 TAB $57.77 250 $40.44 $28.88 $46.22 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAVASTATIN 10 MG TAB UD 1 TAB $11.25 250 $7.88 $5.63 $9.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAVASTATIN 20 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAVASTATIN 40 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAZIQUANTEL 600 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAZOSIN 1 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAZOSIN 2 MG CAP UD 1 CAP $5.34 250 $3.74 $2.67 $4.27 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRAZOSIN 5 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISOLONE 15 MG/5 ML SYR 5 ML J7510 $6.75 636 $4.72 $3.37 $5.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISOLONE OPHTHALMIC ACETATE 1% - OPHTH 1 GTT $11.03 250 $7.72 $5.51 $8.82 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISOLONE OPHTHALMIC ACETATE 1% 10 ML 1 GTT $386.89 250 $270.82 $193.45 $309.51 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISOLONE OPHTHALMIC ACETATE 1% SUSP 5 ML 1 GTT $193.62 250 $135.53 $96.81 $154.90 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISONE 1 MG TAB UD 1 TAB J7512 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISONE 10 MG TAB UD 1 TAB J7512 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISONE 2.5 MG TAB 1 TAB J7512 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISONE 20 MG TAB UD 1 TAB J7512 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISONE 5 MG TAB UD 1 TAB J7512 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISONE 5 MG/5 ML ORAL SYG 5 ML J7512 $14.00 636 $9.80 $7.00 $11.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREDNISONE 50 MG TAB UD 1 TAB J7512 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREGABALIN 100 MG CAP UD - NF 1 CAP $39.67 250 $27.77 $19.83 $31.73 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREGABALIN 150 MG CAP - NF 1 CAP $36.06 250 $25.24 $18.03 $28.85 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREGABALIN 25 MG CAP 1 CAP $36.06 250 $25.24 $18.03 $28.85 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREGABALIN 50 MG CAP - NF 1 CAP $39.67 250 $27.77 $19.83 $31.73 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PREGABALIN 75 MG CAP 1 CAP $39.67 250 $27.77 $19.83 $31.73 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRENATAL MULTIVITAMINS W/ FOLIC ACID 0.8 MG TAB 1 EA S0197 $4.00 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRIMAQUINE 26.3 MG (15MG BASE) TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRIMIDONE 250 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PRIMIDONE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROBENECID 500 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROCAINAMIDE INJ 500 MG/ML 2ML 2 ML J2690 "$1,260.00 " 636 $882.00 $630.00 "$1,008.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROCAINAMIDE VL 100 MG/ML 10 ML 10 ML J2690 $364.61 636 $255.23 $182.31 $291.69 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROCARBAZINE 50 MG CAP 1 CAP "$18,053.32 " 250 "$12,637.32 " "$9,026.66 " "$14,442.66 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROCHLORPERAZINE 10 MG TAB UD 1 TAB Q0164 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROCHLORPERAZINE 10 MG/2 ML INJ VIAL 2 ML J0780 $77.70 636 $54.39 $38.85 $62.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROCHLORPERAZINE 25 MG SUP UD 1 SUPP $5.00 250 $3.50 $2.50 $4.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROCHLORPERAZINE 5 MG TAB UD 1 TAB Q0164 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROGESTERONE 100 MG CAP 1 CAP $7.35 250 $5.15 $3.68 $5.88 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROGESTERONE 100 MG CAP 1 CAP $7.35 250 $5.15 $3.68 $5.88 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROMETHAZINE 12.5 MG TAB (NF) 1 TAB Q0169 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROMETHAZINE 25 MG INJ 1 ML AMP 1 ML J2550 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPAFENONE 150 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPAFENONE 225 MG TAB 1 TAB $8.15 250 $5.71 $4.08 $6.52 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PROPHYLACTIC (CONDOM), LATEX LUBRICATED" 1 KIT $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPOFOL 10 MG/ML INJ 20 ML VL 20 ML J2704 $25.20 636 $17.64 $12.60 $20.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPRANOLOL 1 MG INJ 1ML VL 1 ML J1800 $33.60 636 $23.52 $16.80 $26.88 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPRANOLOL 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPRANOLOL 20 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPRANOLOL 4 MG/1 ML ORAL SOLN 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPRANOLOL 40 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPRANOLOL 80 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROPYLTHIOURACIL 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "PROPYLTHIOURACIL RECTAL ENEMA, TOTAL VOLUME 90 ML" $25.20 250 $17.64 $12.60 $20.16 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROTAMINE 10 MG/ML INJ 25 ML VL 25 ML J2720 $154.81 636 $108.36 $77.40 $123.84 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PROTAMINE 10 MG/ML INJ 5 ML VL 1 VIAL J2720 $13.00 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PSEUDOEPHEDRINE 30 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PSYLLIUM 3.4 G/1 PKT (5.8 G) POW UD 1 PKT $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PSYLLIUM 3.4 G/7 G PWD 390 GM 1 TBSP $18.03 250 $12.62 $9.02 $14.43 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PSYLLIUM 3.4 GM/1 (12 G) PKT PWD UD 1 PKT $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PTU 5 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PYRAZINAMIDE 100 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PYRAZINAMIDE 500 MG TAB UD 1 TAB $5.10 250 $3.57 $2.55 $4.08 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PYRETHRINS 0.33%/PIPERONYL 4% SHAMPOO 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PYRIDOSTIGMINE 180 MG ER TAB 1 TAB $5.39 250 $3.77 $2.69 $4.31 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PYRIDOSTIGMINE 60 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PYRIDOSTIGMINE 60 MG/5 ML ORAL SYG 5 ML $61.87 250 $43.31 $30.93 $49.49 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PYRIDOXINE 100 MG INJ 1 ML VL 1 ML J3415 $69.59 636 $48.72 $34.80 $55.68 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PYRIDOXINE 50 MG (VIT B6) TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY PYRIMETHAMINE 25 MG TAB 1 TAB $70.00 250 $49.00 $35.00 $56.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUETIAPINE 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUETIAPINE 150 MG ERT (NF) 1 TAB $61.93 250 $43.35 $30.97 $49.55 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUETIAPINE 200 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUETIAPINE 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUETIAPINE 300 MG ER TAB 1 TAB $80.43 250 $56.30 $40.22 $64.35 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUETIAPINE 300 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUETIAPINE 50 MG ER TAB 1 TAB $31.04 250 $21.73 $15.52 $24.83 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUETIAPINE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUININE SULF CAP 324 MG 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY QUININE SULFATE 100 MG/ML ORAL SYRG (PED) 1 ML $25.64 250 $17.95 $12.82 $20.51 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "RABIES IMMUNE GLOBULIN, HUMAN 1500 U/10ML INJ" 1 ML "$11,911.34 " 250 "$8,337.94 " "$5,955.67 " "$9,529.07 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "RABIES IMMUNE GLOBULIN, HUMAN 300 U/2ML INJ" 2 ML "$2,609.67 " 250 "$1,826.77 " "$1,304.84 " "$2,087.74 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "RABIES VACCINE, HUMAN DIPLOID CELL INJ 1 ML (NF)" 1 ML "$1,571.50 " 250 "$1,100.05 " $785.75 "$1,257.20 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "RABIES VACCINE, PURIFIED CHICK EMBRYO CELL INJ 1 ML" 1 ML "$1,516.17 " 250 "$1,061.32 " $758.08 "$1,212.93 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RACEPINEPHRINE 2.25% INH 0.5ML UD 0.5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RADIUM RA 223 DICHLORIDE (XOFIGO) INJ 6 ML A9606 "$108,416.95 " 344 "$75,891.87 " "$54,208.48 " "$86,733.56 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges PHARMACY RALOXIFENE 60 MG TAB - NF 1 TAB $24.92 250 $17.44 $12.46 $19.94 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RALTEGRAVIR 100 MG PWD PCKT UD $30.37 250 $21.26 $15.18 $24.29 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RALTEGRAVIR 25 MG TAB - NF 1 TAB $7.59 250 $5.31 $3.80 $6.07 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RALTEGRAVIR 400 MG TAB 1 TAB $36.58 250 $25.60 $18.29 $29.26 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RAMUCIRUMAB 10 MG/ML (SDV) INJ 10ML - NF 10 ML J9308 "$2,044.62 " 636 "$1,431.24 " "$1,022.31 " "$1,635.70 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RAMUCIRUMAB 10 MG/ML (SDV) INJ 50ML - NF 50 ML J9308 "$9,811.48 " 636 "$6,868.04 " "$4,905.74 " "$7,849.19 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RANIBIZUMAB OPHTHALMIC 0.3 MG INJ - NF 0.05 ML J2778 "$4,914.00 " 636 "$3,439.80 " "$2,457.00 " "$3,931.20 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RANIBIZUMAB OPHTHALMIC 0.5 MG INJ - NF 0.05 ML J2778 "$8,190.00 " 636 "$5,733.00 " "$4,095.00 " "$6,552.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RANOLAZINE 1000 MG ER - NF 1 TAB $47.25 250 $33.08 $23.63 $37.80 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RANOLAZINE 500 MG ER - NF 1 TAB $5.88 250 $4.12 $2.94 $4.70 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RASBURICASE 1.5 MG (SDV) INJ - NF J2783 "$4,023.73 " 636 "$2,816.61 " "$2,011.86 " "$3,218.98 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RAVULIZUMAB 10 MG/ML INJ 30 ML VL 1 ML J1303 "$17,011.84 " 636 "$11,908.29 " "$8,505.92 " "$13,609.47 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RAVULIZUMAB 100 MG/ML (SDV) INJ 3 ML J1303 "$8,965.60 " 636 "$6,275.92 " "$4,482.80 " "$7,172.48 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RAVULIZUMAB 100 MG/ML INJ 11 ML VL 1 ML J1303 "$6,301.01 " 636 "$4,410.71 " "$3,150.50 " "$5,040.81 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY REGADENOSON 0.4 MG/5 ML INJ 5 ML J2785 "$1,051.05 " 636 $735.74 $525.53 $840.84 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY REMDESIVIR 100 MG (SDV) INJ "$2,184.00 " 250 "$1,528.80 " "$1,092.00 " "$1,747.20 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY REMDESIVIR 100 MG INJ - EUA 1 EA $20.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY REMIFENTANIL 1 MG INJ VL "$2,574.22 " 250 "$1,801.95 " "$1,287.11 " "$2,059.37 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY REMIFENTANIL 2 MG INJ "$5,148.40 " 250 "$3,603.88 " "$2,574.20 " "$4,118.72 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RENACIDIN IRRIG 500 ML 500 ML $147.00 250 $102.90 $73.50 $117.60 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RHO (D) IG 1000 MCG (WINRHO 5000 IU) 4.4 ML J2792 "$7,249.45 " 636 "$5,074.62 " "$3,624.73 " "$5,799.56 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RHO (D) IG 300 MCG (WINRHO 1500 IU) 1.3 ML J2792 "$1,662.58 " 636 "$1,163.81 " $831.29 "$1,330.06 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIBAVIRIN 200 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIBAVIRIN 200 MG CAP (NF) 1 CAP $34.77 250 $24.34 $17.38 $27.81 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIBOCICLIB 200 MG TAB 1 EA "$1,310.03" 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFABUTIN 150 MG CAP 1 CAP $12.39 250 $8.68 $6.20 $9.92 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFABUTIN 20MG/ML SUSP ORAL SYR 1 ML $61.23 250 $42.86 $30.61 $48.98 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFAMPIN 150 MG CAP 1 CAP $6.96 250 $4.87 $3.48 $5.57 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFAMPIN 300 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFAMPIN 50 MG/ML ORAL SYRG (PED) 1 ML $5.10 250 $3.57 $2.55 $4.08 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFAMPIN 6 MG/ML (DIL 1:10 NS) 1 ML $73.63 250 $51.54 $36.81 $58.90 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFAMPIN 600 MG INJ VL 10 ML $749.95 250 $524.96 $374.97 $599.96 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFAPENTINE 150 MG TAB UD 1 TAB $17.67 250 $12.37 $8.84 $14.14 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFAXIMIN 200 MG TAB 1 TAB $101.26 250 $70.89 $50.63 $81.01 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIFAXIMIN 550 MG TAB UD 1 TAB $193.02 250 $135.12 $96.51 $154.42 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RILPIVIRINE 25 MG TAB 1 TAB $170.48 250 $119.34 $85.24 $136.39 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RILPIVIRINE/EMTRICITABINE/TENOFOVIR 25 MG-200 MG-300 MG (COMPLERA) TAB (NF) 1 TAB $432.40 250 $302.68 $216.20 $345.92 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RILUZOLE 50 MG TAB - NF 1 TAB $130.64 250 $91.45 $65.32 $104.51 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIMANTADINE 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIMEXOLONE OPHT 1% SUS 5ML BTL 1 GTT $337.60 250 $236.32 $168.80 $270.08 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 0.25 MG TAB 1 TAB $13.65 250 $9.56 $6.83 $10.92 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 0.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 1 MG ODT TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 1 MG/ML ORAL SYG 1 ML $17.78 250 $12.44 $8.89 $14.22 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 2 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 25 MG - NF J2794 "$2,238.22 " 636 "$1,566.75 " "$1,119.11 " "$1,790.57 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 3 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 37.5 MG - NF J2794 "$3,357.48 " 636 "$2,350.24 " "$1,678.74 " "$2,685.98 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 4 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE 50 MG - NF J2794 "$4,476.75 " 636 "$3,133.72 " "$2,238.37 " "$3,581.40 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE ODT 0.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RISPERIDONE ODT 2 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RITONAVIR 100 MG POW 1 EA $36.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RITONAVIR 100 MG TAB 1 TAB $22.41 250 $15.69 $11.21 $17.93 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RITONAVIR 80 MG/ML ORAL SYG 1 ML $25.20 250 $17.64 $12.60 $20.16 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RITUXIMAB 10 MG/ML INJ (SDV) 10 ML VL 10 ML J9312 $830.11 636 $581.08 $415.06 $664.09 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RITUXIMAB 10 MG/ML INJ (SDV) 50 ML VL 50 ML J9312 "$3,695.48 " 636 "$2,586.84 " "$1,847.74 " "$2,956.39 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RITUXIMAB ABBS 10 MG/ML INJ (SDV) 10 ML 1 EA Q5115 $150.66 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RITUXIMAB ABBS 10 MG/ML INJ (SDV) 50 ML 1 EA Q5115 $150.58 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIVAROXABAN 10 MG TAB 1 TAB $68.95 250 $48.26 $34.47 $55.16 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIVAROXABAN 15 MG TAB 1 TAB $68.95 250 $48.26 $34.47 $55.16 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY RIVAROXABAN 20 MG TAB 1 TAB $68.95 250 $48.26 $34.47 $55.16 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROCURONIUM 10 MG/ML INJ 5ML VL 1 ML $15.53 250 $10.87 $7.77 $12.43 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROMIDEPSIN 10 MG INJ - NF J9319 "$12,294.28 " 636 "$8,605.99 " "$6,147.14 " "$9,835.42 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROMIPLOSTIM 125 MCG INJ (SDV) - NF J2796 "$3,903.03 " 636 "$2,732.12 " "$1,951.51 " "$3,122.42 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROMIPLOSTIM 250 MCG INJ (SDV) J2796 "$6,118.00 " 636 "$4,282.60 " "$3,059.00 " "$4,894.40 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROMIPLOSTIM 500 MCG INJ (SDV) J2796 "$9,786.84 " 636 "$6,850.79 " "$4,893.42 " "$7,829.47 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROPINIROLE 0.25 MG TAB (NF) 1 TAB $8.84 250 $6.19 $4.42 $7.07 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROPINIROLE 0.5 MG TAB - NF 1 TAB $8.75 250 $6.12 $4.37 $7.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROPINIROLE 1 MG TAB UD 1 TAB $8.75 250 $6.12 $4.37 $7.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROPINIROLE 5 MG TAB 1 EA $8.75 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROPIVACAINE 0.2% (2MG/ML) 100 ML INJ VIAL 100 ML J2795 $252.00 636 $176.40 $126.00 $201.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROPIVACAINE 0.2% (2MG/ML) 20 ML INJ VIAL 20 ML J2795 $15.33 636 $10.73 $7.67 $12.27 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROPIVACAINE 0.5% PF INJ 20 ML 1 ML J2795 $88.20 636 $61.74 $44.10 $70.56 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROSUVASTATIN 10 MG TAB UD 1 TAB $25.00 250 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROSUVASTATIN 20 MG TAB 1 TAB $25.00 250 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROSUVASTATIN 40 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROSUVASTATIN 5 MG TAB UD 1 TAB $25.00 250 $17.50 $12.50 $20.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ROTAVIRUS (ROTATEQ) VACCINE SUSP 2 ML 2 ML $376.94 250 $263.86 $188.47 $301.55 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "RSV VACCINE, PREF A-PREF B, RECOMBINANT PRESERVATIVE-FREE 60 MCG-60 MCG INJ" 1 EA 90678 "$1,239.00" 254 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SACITUZUMAB GOVITECAN-HZIY 180 MG (SDV) INJ J9317 "$8,450.40 " 636 "$5,915.28 " "$4,225.20 " "$6,760.32 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SACUBITRIL-VALSARTAN 24 MG-26 MG TAB - NF 1 TAB $40.80 250 $28.56 $20.40 $32.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SACUBITRIL-VALSARTAN 49 MG-51 MG TAB - NF 1 TAB $40.80 250 $28.56 $20.40 $32.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SACUBITRIL-VALSARTAN 97 MG-103 MG TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SALICYLIC ACID 17% LIQ 15ML 1 APP $17.47 250 $12.23 $8.73 $13.97 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SALICYLIC ACID TOP 40% PLASTER PAD 1 PAD $85.58 250 $59.90 $42.79 $68.46 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SALMETEROL 50 MCG POWDER #28 BLISTERS (NF) 1 INHALATION "$1,019.38 " 250 $713.56 $509.69 $815.50 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SALMETEROL 50 MCG/INH DISKUS MDI 1 INHALATION $27.94 250 $19.56 $13.97 $22.35 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SALSALATE 500 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SALSALATE 750 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SAQUINAVIR 500 MG TAB 1 TAB $15.90 250 $11.13 $7.95 $12.72 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SARGRAMOSTIM 250 MCG POW J2820 "$5,197.62 " 636 "$3,638.33 " "$2,598.81 " "$4,158.09 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SCOPOLAMINE HYDROBROMIDE 1 MG PATCH/24 HR 1 PATCH $80.41 250 $56.29 $40.20 $64.33 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SECRETIN SYNTHETIC HUMAN 0.016 MG POW J2850 "$1,137.50 " 636 $796.25 $568.75 $910.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SELEGILINE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SELENIUM 40 MCG/ML INJ 10 ML VL 10 ML $77.57 250 $54.30 $38.78 $62.05 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SELENIUM 60 MCG/ML INJ 1 ML $144.06 250 $100.84 $72.03 $115.25 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SELENIUM SULF 2.5% LOTION SHAMPOO 120 ML 1 APP $69.30 250 $48.51 $34.65 $55.44 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SELENIUM SULFIDE TOPICAL 1% SHAMPOO 1 APP $16.00 250 $11.20 $8.00 $12.80 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SENNA 8.6 MG TAB UD (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SERTRALINE 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SERTRALINE 20 MG/ML ORAL CONCENTRATE - NF 1 ML $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SERTRALINE 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SERTRALINE 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SEVELAMER 400 MG TAB 1 TAB "$4,991.45 " 250 "$3,494.01 " "$2,495.72 " "$3,993.16 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SEVELAMER 800 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SEVELAMER CARBONATE 0.8 G POW - NF 1 PKT $74.96 250 $52.47 $37.48 $59.97 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SEVELAMER CARBONATE 800 MG TAB UD 1 TAB $28.12 250 $19.68 $14.06 $22.50 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SEVOFLURANE INH 250ML BTL 250 ML $982.73 250 $687.91 $491.37 $786.18 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SILDENAFIL 20 MG TAB 1 TAB $70.80 250 $49.56 $35.40 $56.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SILDENAFIL 25 MG TAB 1 TAB $326.83 250 $228.78 $163.42 $261.47 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SILDENAFIL 2MG/ML ORAL SYR (PED) 1 ML $121.86 250 $85.30 $60.93 $97.49 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SILVER NITRATE TOPICAL SWAB 100 BTL 1 SWAB $233.10 250 $163.17 $116.55 $186.48 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SILVER SULFADIAZINE 1% CRE 1000GM 1 APP $507.99 250 $355.59 $254.00 $406.39 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SILVER SULFADIAZINE 1% CREAM 50GM 1 APP $52.92 250 $37.04 $26.46 $42.34 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SILVER SULFADIAZINE 1% CRM 400 GM JAR 1 APP $227.33 250 $159.13 $113.67 $181.87 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SIMETHICONE 40MG/0.6 ML LIQ 30ML 0.6 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SIMETHICONE 80 MG CHEW TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SIROLIMUS 1 MG TAB 1 TAB J7520 $34.97 636 $24.48 $17.49 $27.98 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SIROLIMUS 1 MG TAB NF 1 TAB J7520 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SITAGLIPTIN 100 MG TAB - NF 1 TAB $66.28 250 $46.39 $33.14 $53.02 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SITAGLIPTIN 50 MG TAB - NF 1 TAB $66.28 250 $46.39 $33.14 $53.02 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD BICARBONATE 650 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD BICARBONATE 8.4% INJ 10 ML SYG 10 ML $61.57 250 $43.10 $30.79 $49.26 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD BICARBONATE 8.4% INJ 50 ML SYG 50 ML $45.47 250 $31.83 $22.74 $36.38 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD BIPHOSPHATE-SOD PHOS (PED) 3.5 G-9.5 G 66 ML 1 ENEMA $5.25 250 $3.68 $2.63 $4.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD CHL 0.65% NASAL SPRAY 45ML 1 SPRAY $7.35 250 $5.15 $3.68 $5.88 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD CHL 0.9% 1000 ML IRRIGATION BAG 1000 ML $22.05 250 $15.44 $11.03 $17.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD CHL 0.9% INH 3ML UD 1 NEB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD CHLORIDE OPH 5% SOL 15ML BTL 1 GTT $51.59 250 $36.11 $25.80 $41.27 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD CHLORIDE OPHT 5% OIN 3.5 GM 0.5 INCH $45.82 250 $32.07 $22.91 $36.65 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD FERRIC GLUC 12.5 MG/ML (SDV) INJ 5 ML AMP 5 ML J2916 $26.71 636 $18.70 $13.36 $21.37 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD HYA CHONDROITIN OPH 0.5ML SYR 0.5 ML $672.35 250 $470.65 $336.18 $537.88 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD HYA CHONDROITIN OPH 0.75ML SYR 0.75 ML "$1,177.96 " 250 $824.57 $588.98 $942.37 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD HYPOCHLORITE 0.25% SOL 480ML 1 APP $48.51 250 $33.95 $24.25 $38.80 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD HYPOCHLORITE 0.5% SOL 480ML 1 APP $48.82 250 $34.17 $24.41 $39.06 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOD POLY SULFONATE 15 GM/60 ML UD 60 ML $83.65 250 $58.55 $41.82 $66.92 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM ACETATE 2 MEQ/ML INJ 100 ML 1 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM ACETATE 2 MEQ/ML INJ 20ML VL 1 ML $13.30 250 $9.31 $6.65 $10.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM ACETATE 2 MEQ/ML INJ 50 ML VL - FOR TPN USE 50 ML $531.86 250 $372.30 $265.93 $425.49 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM ACETATE 4 MEQ/ML INJ 100 ML 100 ML $37.00 250 $25.90 $18.50 $29.60 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM BICARBONATE 4.2% INJ 10 ML SYR 10 ML $47.67 250 $33.37 $23.84 $38.14 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM BICARBONATE 8.4% INJ (SDV) 10 ML VL 10 ML $12.60 250 $8.82 $6.30 $10.08 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM BICARBONATE 8.4% INJ 50 ML VL 50 ML $40.90 250 $28.63 $20.45 $32.72 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM BIPHOSPHATE-SODIUM PHOSPHATE 7 G-19 G ENE 1 ENEMA $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM CHLORIDE 0.9% 250 ML IVPB SOLN ADD-VANTAGE 250 ML J7040 $13.90 636 $9.73 $6.95 $11.12 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges PHARMACY SODIUM CHLORIDE 0.9% PF INJ 20 ML 20 ML A4216 $10.00 272 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY SODIUM CHLORIDE 0.9% SOL (PF) 50ML VL 1 ML A4216 $10.71 272 $7.50 $5.36 $8.57 65% 80% 50% 50% 65% 65% 65% PHARMACY SODIUM CHLORIDE 0.9% SOL [PF] 10ML VL 10 ML A4216 $10.00 272 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY SODIUM CHLORIDE 1 G TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM CHLORIDE 1.5% 1000ML 1000 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM CHLORIDE 23.4% INJ 1 ML J7131 $39.53 636 $27.67 $19.76 $31.62 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM CHLORIDE 3% NEB SOLN UD 1 NEB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM CHLORIDE 4 MEQ/ML 5ML ORAL SYR 1 ML J7131 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM CHLORIDE 6% NEBULIZED SOLUTION 4 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM CHLORIDE BACTERIOSTATIC 0.9% INJ 10 ML - FOR INPATIENT PHARMACY USE ONLY 10 ML $10.00 250 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "SODIUM CHLORIDE, HYPERTONIC, OPHTHALMIC 5% SOLN 15 ML (NF)" 1 GTT $51.59 250 $36.11 $25.80 $41.27 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM CHONDROITIN-HYALURONATE OPHTHALMIC - KIT (NF) 1 KIT $890.07 250 $623.05 $445.03 $712.05 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM GLYCEROPHOSPHATE 20 MMOL / 20 ML SOL 20 ML $54.60 250 $38.22 $27.30 $43.68 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM HYALURONATE 10 MG/ML (GEL-ONE) INJ 1 ML J7326 "$1,610.00 " 636 "$1,127.00 " $805.00 "$1,288.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM HYALURONATE 10% 1 EA $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM HYALURONATE 10% / 30% (HEALON DUET) INJ 1 KIT $704.38 250 $493.06 $352.19 $563.50 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM HYALURONATE 20 MG/ML (DUROLANE) INJ - NF 3 ML J7318 "$4,217.85 " 636 "$2,952.50 " "$2,108.93 " "$3,374.28 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM HYALURONATE OPHTHALMIC (HEALON ENDOCOAT) 0.85 ML INJ 1 EA $788.12 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM HYALURONATE OPHTHALMIC (HEALON PRO) 0.55 ML SYR INJ 1 EA $866.03 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM HYALURONATE OPHTHALMIC 14% (HEALON GV) INJ - NF 0.85 ML $252.74 250 $176.92 $126.37 $202.19 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM HYALURONATE OPHTHALMIC 23% (HEALON 5) INJ - NF 1 SYRINGE $297.50 250 $208.25 $148.75 $238.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM PHOSPHATE 3 MMOL/ML INJ 15 ML VL 1 ML $138.64 250 $97.05 $69.32 $110.91 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM PHOSPHATE 3 MMOL/ML INJ 5 ML 1 ML $67.79 250 $47.45 $33.89 $54.23 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM POLYSTYRENE SULFONATE 15 G/60 ML SUS 120 ML ENEMA 120 ML $376.25 250 $263.37 $188.12 $301.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM TETRADECYL SULFATE 1% SOL - NF 2 ML $328.13 250 $229.69 $164.07 $262.51 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SODIUM THIOSULFATE 12.5 GM / 50 ML INJ 50 ML $374.50 250 $262.15 $187.25 $299.60 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOFOSBUVIR-VELPATASVIR 400 MG / 100 MG - NF 1 TAB "$1,200.00 " 250 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOLIFENACIN 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOMATROPIN 5 MG INJ VL J2941 "$1,218.00 " 636 $852.60 $609.00 $974.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SORBITOL 70% ORAL LIQ 30ML UD 30 ML $10.34 250 $7.24 $5.17 $8.27 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOTALOL 120 MG TAB UD - NF 1 TAB $11.97 250 $8.38 $5.98 $9.57 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOTALOL 160 MG TAB 1 TAB $14.96 250 $10.47 $7.48 $11.97 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SOTALOL 80 MG TAB UD 1 TAB $8.12 250 $5.68 $4.06 $6.50 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SPIRONOLACTONE 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SPIRONOLACTONE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SPIRONOLACTONE 5 MG/ML ORAL SYRG (PED) 1 ML $13.57 250 $9.50 $6.78 $10.85 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SPIRONOLACTONE 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY STERILE TALC POWDER INJ (FOR PLEURODESIS) 100 ML $588.00 250 $411.60 $294.00 $470.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY STOMATITIS COCKTAIL-ALOH/DIPHENHYD/LIDOCAINE/MGOH/SIMETH 237 ML SUS 15 ML $336.00 250 $235.20 $168.00 $268.80 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY STREPTOMYCIN INJ 1 GM VL 10 ML J3000 "$3,281.25 " 636 "$2,296.88 " "$1,640.63 " "$2,625.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY STREPTOZOCIN 1 GM INJ VL J9320 "$1,466.78 " 636 "$1,026.75 " $733.39 "$1,173.42 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUBCONJUNCTIVAL MITOMYCIN 0.2 MG / ML OPHTH 1 ML J7315 $44.28 636 $30.99 $22.14 $35.42 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUBCONJUNCTIVAL MITOMYCIN 0.5 MG/ ML OPHTH 1 ML J7315 $10.00 636 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUCCIMER 100 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUCCINYLCHOLINE 20 MG/ML INJ 10 ML VL 10 ML J0330 $83.91 636 $58.74 $41.96 $67.13 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUCRALFATE 1 G/10 ML SUS NF 10 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUCRALFATE 1 GM /10 ML CUP 10 ML $49.02 250 $34.31 $24.51 $39.21 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUCRALFATE 1 GM TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUCROSE 24% SOLN 1 ML 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUFENTANIL 50 MCG/ML INJ 1 ML AMP 1 ML $18.84 250 $13.19 $9.42 $15.07 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUFENTANIL 50 MCG/ML INJ 2 ML AMP 2 ML $31.82 250 $22.27 $15.91 $25.45 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUFENTANIL 50 MCG/ML INJ 5 ML AMP 1 ML $67.20 250 $47.04 $33.60 $53.76 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUGAMMADEX 100 MG/ML INJ 2ML 2 ML $219.91 250 $153.94 $109.96 $175.93 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULFADIAZINE 500 MG TAB 1 TAB $4.82 250 $3.38 $2.41 $3.86 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULFAMETHOXAZOLE-TRIMETHOPRIM 400 MG-80 MG TAB (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULFAMETHOXAZOLE-TRIMETHOPRIM 80MG-16 MG/ML INJ 1 ML $157.99 250 $110.59 $79.00 $126.39 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULFAMETHOX-TRIM (DS) 800/160 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULFAMETHOX-TRIM (SS) 400 MG/80 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULFAMET-TRIMET 200/40 MG ORAL SYG 5 ML $4.18 250 $2.92 $2.09 $3.34 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULFASALAZINE 500 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULFASALAZINE ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULFUR-SALICYLIC ACID TOPICAL 2%-2% SHA 1 APP $15.51 250 $10.85 $7.75 $12.41 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULINDAC 150 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SULINDAC 200 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUMATRIPTAN 100 MG TAB UD 1 TAB $87.99 250 $61.60 $44.00 $70.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUMATRIPTAN 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUMATRIPTAN 25 MG TAB (NF) 1 TAB $133.51 250 $93.46 $66.76 $106.81 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUMATRIPTAN 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUMATRIPTAN 6 MG/0.5 ML (SDV) INJ 0.5 ML J3030 $297.50 636 $208.25 $148.75 $238.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SUNBLOCK SPF 30 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY SURGILUBE 5GM FOILPAK 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TACROLIMUS 0.5 MG CAP UD 1 CAP J7507 $7.80 636 $5.46 $3.90 $6.24 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TACROLIMUS 1 MG CAP UD 1 CAP J7507 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TACROLIMUS 5 MG CAP 1 CAP J7507 $26.50 636 $18.55 $13.25 $21.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TACROLIMUS TOPICAL 0.1% OIN 30GM TU - NF 1 APP $420.00 250 $294.00 $210.00 $336.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TAFASITAMAB 200 MG INJ J9349 "$5,115.60 " 636 "$3,580.92 " "$2,557.80 " "$4,092.48 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TAFENOQUINE 150 MG TAB UD 1 TAB $67.20 250 $47.04 $33.60 $53.76 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TALC USP 113 GM BTL 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TAMOXIFEN 10 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TAMSULOSIN 400 MCG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TAZAROTENE TOPICAL 0.1% CREAM 1 TUBE $45.48 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TBO-FILGRASTIM 300 MCG/0.5 ML INJ 0.5 ML J1447 "$1,908.02 " 636 "$1,335.61 " $954.01 "$1,526.41 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TBO-FILGRASTIM 480 MCG/0.8 ML INJ 0.8 ML J1447 "$1,908.56 " 636 "$1,335.99 " $954.28 "$1,526.85 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TD - ADULT/ADOLES (TENIVAC) VACCINE INJ 0.5 ML 0.5 ML $150.72 250 $105.50 $75.36 $120.57 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TDAP - ADULT/ADOLES (BOOSTRIX) VACCINE INJ 0.5 ML 0.5 ML $176.33 250 $123.43 $88.17 $141.06 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TECLISTAMAB CQYV 10 MG/ML SOL 1 EA J9380 "$1,398.00" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TECLISTAMAB CQYV 90 MG/ML SOL 1 EA J9380 "$11,782.00" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TEMOZOLOMIDE 100 MG CAP 1 CAP J8700 $15.18 636 $10.62 $7.59 $12.14 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TEMOZOLOMIDE 100 MG CAP (NF) 1 CAP J8700 $826.37 636 $578.46 $413.18 $661.09 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TEMOZOLOMIDE 20 MG CAP 1 CAP J8700 $4.00 636 $2.80 $2.00 $3.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TEMOZOLOMIDE 250 MG CAP 1 CAP J8700 $227.42 636 $159.20 $113.71 $181.94 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TEMOZOLOMIDE 250 MG CAP (NF) 1 CAP J8700 "$2,801.55 " 636 "$1,961.09 " "$1,400.78 " "$2,241.24 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TEMOZOLOMIDE 5 MG CAP 1 CAP J8700 $105.63 636 $73.94 $52.82 $84.51 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TEMSIROLIMUS 25 MG/ML DILUTED TO 10 MG/ML INJ (SDV) 2.5 ML J9330 "$4,956.00 " 636 "$3,469.20 " "$2,478.00 " "$3,964.80 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TENECTEPLASE 50 MG INJ VL J3101 "$27,294.58 " 636 "$19,106.20 " "$13,647.29 " "$21,835.66 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TENOFOV ALAFEN-EMTRICIT (DESCOVY) 200 MG-25 MG TAB 1 TAB $270.30 250 $189.21 $135.15 $216.24 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TENOFOVIR 25 MG TAB - NF 1 TAB $181.68 250 $127.17 $90.84 $145.34 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TENOFOVIR 300 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TENOFOVIR 40 MG/G POWDER - NF 1 SCOOP $47.84 250 $33.49 $23.92 $38.28 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TEPROTUMUMAB TRBW 500 MG POW 1 EA J3241 "$64,980.72" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TERAZOSIN 1 MG CAP UD (NF) 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TERAZOSIN 2MG CAP (NF) 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TERBINAFINE 250 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TERBUTALINE 1 MG/ML INJ 1 ML AMP 1 ML J3105 $16.80 636 $11.76 $8.40 $13.44 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TERBUTALINE 2.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TERCONAZOLE VAG 0.4% CRE 45GM TU 1 APP $155.89 250 $109.12 $77.95 $124.71 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TERIFLUNOMIDE 7 MG TAB 1 TAB "$1,137.62" 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TERIPARATIDE 600 MCG/2.4 ML DEV - NF 2.4 ML J3110 "$6,611.00 " 636 "$4,627.70 " "$3,305.50 " "$5,288.80 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TESTOSTERONE 2 MG/24 HR PAT - NF 1 PATCH $35.79 250 $25.06 $17.90 $28.64 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TESTOSTERONE 4 MG/24 HR PAT - NF 1 PATCH $86.23 250 $60.36 $43.11 $68.98 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TESTOSTERONE 40.5 MG/2.5 G (1.62%) GEL 1 PKT $35.86 250 $25.10 $17.93 $28.69 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TESTOSTERONE 50 MG/5 G GEL PKT (NF) 1 PKT $17.93 250 $12.55 $8.97 $14.34 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TESTOSTERONE CYPIO 200 MG/ML 1ML (SDV) 1 ML J1071 $78.75 636 $55.13 $39.38 $63.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TETANUS IMMUNE GLOB 250 UNITS INJ 1 ML J1670 "$2,336.88 " 636 "$1,635.82 " "$1,168.44 " "$1,869.50 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TETRACAINE 20 MG SPINAL 2-ML AMP 2 ML $318.95 250 $223.27 $159.48 $255.16 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TETRACAINE OP SOL 0.5% - OPHTH 1 GTT $7.49 250 $5.24 $3.74 $5.99 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TETRACAINE OPHT 0.5% 4 ML BTL 1 GTT $11.12 250 $7.78 $5.56 $8.90 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TETRACAINE OPHT 0.5% 15ML BTL 1 GTT $378.00 250 $264.60 $189.00 $302.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THALIDOMIDE 50 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THEOPHYLLINE 100 MG ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THEOPHYLLINE 2 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THEOPHYLLINE 200 MG ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THEOPHYLLINE 300 MG ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THEOPHYLLINE 400 MG ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THEOPHYLLINE 80 MG/15 ML ORAL SYG 15 ML $43.75 250 $30.62 $21.87 $35.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THIAMINE 100 MG (VIT B1) TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THIAMINE 100 MG/ML INJ 2 ML VL 2 ML J3411 $41.79 636 $29.25 $20.90 $33.43 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THIOGUANINE 40 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THIORIDAZINE 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THIORIDAZINE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THIOTHIXENE 2 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THIOTHIXENE 5 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "THROMBIN 20,000 UNIT VIAL" 1 APP "$1,188.78 " 250 $832.14 $594.39 $951.02 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THROMBIN EPISTAXIS 5000 UNITS KIT (NASAL) 1 APP $324.45 250 $227.12 $162.23 $259.56 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THROMBIN TOPICAL (FLOSEAL) HEMOSTATIC MATRIX 10 ML 1 EA "$1,433.08" 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THROMBIN TOPICAL (FLOSEAL) HEMOSTATIC MATRIX 5 ML 1 EA $899.36 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "THROMBIN TOPICAL 20,000 UNIT SYR KIT" 1 KIT "$1,248.24 " 250 $873.77 $624.12 $998.59 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THROMBIN TOPICAL 5000 UNIT PWD 1 APP $301.42 250 $210.99 $150.71 $241.14 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY THYROTROPIN ALPHA 0.9 MG INJ J3240 "$7,455.13 " 636 "$5,218.59 " "$3,727.56 " "$5,964.10 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TICAGRELOR 90 MG TAB UD 1 TAB $28.90 250 $20.23 $14.45 $23.12 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIGECYCLINE 50 MG (SDV) INJ J3243 "$6,552.00 " 636 "$4,586.40 " "$3,276.00 " "$5,241.60 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIMOLOL OPHT 0.25% SOL 5ML BTL 1 GTT $52.50 250 $36.75 $26.25 $42.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIMOLOL OPHT 0.5% SOL 5ML BTL 1 GTT $22.96 250 $16.07 $11.48 $18.37 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIMOLOL OPHTHALMIC MALEATE 0.5% GEL - NF 1 GTT $152.09 250 $106.46 $76.04 $121.67 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "TIMOLOL OPHTHALMIC MALEATE LONG-ACTING, 0.5% SOL" 1 BTL $245.65 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TINCTURE OF OPIUM 10 MG/ML - NF 0.6 ML $21.98 250 $15.39 $10.99 $17.59 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TINIDAZOLE 500 MG TAB - NF 1 TAB $59.95 250 $41.96 $29.97 $47.96 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIOTROPIUM 18 MCG/INH HANDIHALER #5 CAP 1 INHALATION $75.73 250 $53.01 $37.87 $60.59 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIROFIBAN 250 MCG/ML (SDV) FOR BOLUS INJ 15 ML VL 15 ML J3246 $15.68 636 $10.98 $7.84 $12.54 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIROFIBAN 50 MCG/ML INJ 100 ML (SDV) 100 ML J3246 $386.40 636 $270.48 $193.20 $309.12 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIROFIBAN 50 MCG/ML INJ 250ML PREMIX BAG 250 ML J3246 "$1,405.32" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIROFIBAN 50 MCG/ML INJ 250ML PREMIX BAG J3246 "$1,018.80 " 636 $713.16 $509.40 $815.04 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TISOTUMAB VEDOTIN TFTV 40 MG INJ 1 EA J9273 "$26,678.40" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TIZANIDINE 2 MG CAP 1 CAP $9.49 250 $6.64 $4.75 $7.59 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOBRAMYCIN 10 MG/ML INJ 2 ML 2 ML J3260 $22.18 636 $15.52 $11.09 $17.74 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOBRAMYCIN 1200 MG INJ VL J3260 $350.00 636 $245.00 $175.00 $280.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOBRAMYCIN 40 MG/ML INJ 2 ML VL 2 ML J3260 $14.24 636 $9.97 $7.12 $11.39 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOBRAMYCIN 40 MG/ML INJ 30 ML VL 30 ML J3260 $92.40 636 $64.68 $46.20 $73.92 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOBRAMYCIN 60 MG/ML INH SOL - NF 5 ML J7682 $90.14 636 $63.10 $45.07 $72.11 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOCILIZUMAB 20 MG/ML INJ (SDV) 10 ML 10 ML J3262 "$4,493.92 " 636 "$3,145.74 " "$2,246.96 " "$3,595.13 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOCILIZUMAB 20 MG/ML INJ (SDV) 20 ML 20 ML J3262 "$9,402.33 " 636 "$6,581.63 " "$4,701.17 " "$7,521.86 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOCILIZUMAB 20 MG/ML INJ (SDV) 4 ML 4 ML J3262 $794.33 636 $556.03 $397.16 $635.46 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOLNAFTATE TOPICAL 1% CREAM 1 APP $17.85 250 $12.50 $8.93 $14.28 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOLTERODINE 2 MG LA CAP UD 1 CAP $19.03 250 $13.32 $9.51 $15.22 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOLTERODINE 2 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOLTERODINE 4 MG LA CAP UD 1 CAP $17.36 250 $12.15 $8.68 $13.89 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOLTERODINE LA 2 MG CAP NF 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOLTERODINE LA 4 MG CAP (NF) 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOLVAPTAN 15 MG TAB - NF 1 TAB "$2,184.83 " 250 "$1,529.38 " "$1,092.41 " "$1,747.86 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOPIRAMATE 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOPIRAMATE 25 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOPIRAMATE 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TOPOTECAN 1 MG/ML (SDV) INJ 4 ML 4 ML J9351 $156.45 636 $109.52 $78.23 $125.16 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TORSEMIDE 20 MG TAB - NF 1 TAB $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRABECTEDIN 1 MG INJ (SDV) J9352 "$12,503.44 " 636 "$8,752.41 " "$6,251.72 " "$10,002.75 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "TRACE ELEMENTS NEONATAL (MULTRYS) ZINC, COPPER, MANGANESE, SELENIUM" 1 ML "$2,100.00 " 250 "$1,470.00 " "$1,050.00 " "$1,680.00 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "TRACE ELEMENTS PEDS/ADULT - ZINC 3MG, COPPER 0.3MG, MANGANESE 55MCG, SELENIUM 60 MCG - FOR TPN USE" 1 ML $90.30 250 $63.21 $45.15 $72.24 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRAMADOL 50 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRANEXAMIC ACID 1000 MG / 10ML VL 10 ML $87.33 250 $61.13 $43.67 $69.87 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRANEXAMIC ACID 1000 MG/100 ML NS 100 ML $87.33 250 $61.13 $43.67 $69.87 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRASTUZUMAB 150 MG INJ (SDV) J9355 "$1,367.42 " 636 $957.19 $683.71 "$1,093.94 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRASTUZUMAB 440 MG INJ J9355 "$3,817.76 " 636 "$2,672.43 " "$1,908.88 " "$3,054.21 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRASTUZUMAB DKST 150 MG (SDV) INJ Q5114 "$3,597.10 " 636 "$2,517.97 " "$1,798.55 " "$2,877.68 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRASTUZUMAB DKST 420 MG INJ Q5114 "$2,386.66 " 636 "$1,670.66 " "$1,193.33 " "$1,909.33 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRAZODONE 100 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRAZODONE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TREMELIMUMAB ACTL 20 MG/ML 1.25ML (SDV) 1 VIAL J9347 "$4,383.93" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TREMELIMUMAB ACTL 20MG/ML 15ML (SDV) 1 VIAL J9347 "$4,383.93" 636 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TREPROSTINIL 1 MG/ML INJ 20 ML 1 ML J3285 "$5,080.53 " 636 "$3,556.37 " "$2,540.27 " "$4,064.42 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TREPROSTINIL 2.5 MG/ML INJ 20 ML 1 ML J3285 "$12,701.40 " 636 "$8,890.98 " "$6,350.70 " "$10,161.12 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TREPROSTINIL 5 MG/ML INJ 20 ML 1 ML J3285 "$25,402.72 " 636 "$17,781.90 " "$12,701.36 " "$20,322.18 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRETINOIN 10 MG CAP - NF 1 CAP $41.45 250 $29.02 $20.73 $33.16 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRETINOIN TOP 0.025% CRE 20GM TU 1 APP $446.50 250 $312.55 $223.25 $357.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRETINOIN TOP 0.05% CRE 20GM 1 APP $500.78 250 $350.55 $250.39 $400.62 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRETINOIN TOPICAL 0.01% GEL 1 APP $354.59 250 $248.21 $177.29 $283.67 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRETINOIN TOPICAL 0.025% GEL 1 APP $357.74 250 $250.41 $178.87 $286.19 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRETINOIN TOPICAL 0.04% GEL 1 EA $42.16 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE 0.025% CRE 80GM TU 1 APP $35.39 250 $24.77 $17.69 $28.31 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE 0.025% OIN 80GM TU 1 APP $35.39 250 $24.77 $17.69 $28.31 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE 0.1% CRE 15GM TU 1 APP $13.61 250 $9.53 $6.81 $10.89 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE 0.1% CRE 80GM TU 1 APP $34.58 250 $24.21 $17.29 $27.66 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE 0.1% OIN 15GM TU 1 APP $19.74 250 $13.82 $9.87 $15.79 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE 0.1% OIN 80GM TU 1 APP $44.94 250 $31.46 $22.47 $35.95 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE 10 MG/ML INJ 5ML VL 5 ML J3301 $50.79 636 $35.55 $25.39 $40.63 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE 32 MG INTRA-ARTICULAR INJ - NF J3304 "$2,513.70 " 636 "$1,759.59 " "$1,256.85 " "$2,010.96 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE 40MG/ML (SDV) INJ 1ML 1 ML J3301 $35.70 636 $24.99 $17.85 $28.56 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE ACET 40MG/ML 5ML VL 5 ML J3301 $182.07 636 $127.45 $91.04 $145.66 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE NASAL 55 MCG/INH SPR 1 SPRAY $5.65 250 $3.96 $2.83 $4.52 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE OPHTHALMIC 40 MG/ML INJ 1 ML J3300 $631.72 636 $442.20 $315.86 $505.37 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE TOP 0.1% PAS 5GM TU 1 APP $282.07 250 $197.45 $141.03 $225.65 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE TOPICAL 0.1% DENTAL PASTE 5GM (NF) 1 APP $282.07 250 $197.45 $141.03 $225.65 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAMCINOLONE TOPICAL 0.1% OINT 454 GM 1 EA $4.00 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAZOLAM 125 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIAZOLAM 250 MCG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIFLUOPERAZINE 1 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIFLUOPERAZINE 2 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIFLUOPERAZINE 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIFLURIDINE OPHT 1% SOL 7.5ML BTL 1 GTT $780.29 250 $546.20 $390.14 $624.23 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIFLURIDINE OPHTHALMIC 1% SOL 7.5 ML (NF) 1 APP $780.29 250 $546.20 $390.14 $624.23 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIHEXYPHENIDYL 2 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIHEXYPHENIDYL 5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIMETHOBENZAMID 200MG/2ML INJ 2 ML J3250 $186.82 636 $130.77 $93.41 $149.45 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIMETHOPRIM 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIPLE ANTIBIOTIC OINT PKT UD 1 APP $139.97 250 $97.98 $69.98 $111.97 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIPLE ANTIBIOTIC OINTMENT TUBE 30 G 1 APP $21.52 250 $15.07 $10.76 $17.22 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRIPLE DYE POIN POINT APPLICATORS TOPICAL 1 APP $22.08 250 $15.46 $11.04 $17.67 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TROLAMINE SALICYLATE TOPICAL 10% CREAM 1 APP $11.31 250 $7.91 $5.65 $9.04 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TROPICAMIDE OPHT 0.5% SOL 15ML BTL 15 ML $35.00 250 $24.50 $17.50 $28.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TROPICAMIDE OPHT 1% SOL - OPHTH 1 EA $8.75 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TROPICAMIDE OPHT 1% SOL 15ML BTL 1 GTT $37.28 250 $26.09 $18.64 $29.82 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TROSPIUM 60 MG ER - NF 1 CAP $26.20 250 $18.34 $13.10 $20.96 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TRYPAN BLUE OPHTHALMIC 0.06% OPTH SOL 0.5 ML BTL 1 GTT $280.00 250 $196.00 $140.00 $224.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY TUBERCULIN PPD 5 UNIT INJ 0.1 ML 0.1 ML $373.10 250 $261.17 $186.55 $298.48 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ULIPRISTAL 30 MG TAB 1 TAB $162.75 250 $113.93 $81.38 $130.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY UMECLIDINIUM 62.5 MCG (0.0625 MG)/INH DPI INHALER 1 INHALATION $48.13 250 $33.69 $24.07 $38.50 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY UMECLIDINIUM-VILANTEROL 62.5 MCG-25 MCG/INH POW 1 EA $32.27 250 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY UNNA BOOT - CALAMINE-ZINC OXIDE TOPICAL BANDAGE 1 EA $57.89 250 $40.52 $28.95 $46.31 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY UREA TOPICAL 10% CREAM 1 APP $31.50 250 $22.05 $15.75 $25.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY URSODIOL 20 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY URSODIOL 300 MG CAP UD 1 CAP $10.60 250 $7.42 $5.30 $8.48 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY USTEKINUMAB 45 MG/0.5 ML (SDV) - NF 0.5 ML J3357 "$50,800.72 " 636 "$35,560.50 " "$25,400.36 " "$40,640.57 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY USTEKINUMAB 5 MG/ML 26 ML (SDV) INJ - NF 26 ML J3358 $258.46 636 $180.92 $129.23 $206.77 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY USTEKINUMAB 90 MG/ML (SDV) - NF 1 ML J3357 "$101,601.43 " 636 "$71,121.00 " "$50,800.72 " "$81,281.14 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALACYCLOVIR (VALTREX) 1 GM TAB 1 TAB $7.06 250 $4.94 $3.53 $5.65 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALBENAZINE 60 MG CAP - NF 1 CAP "$1,030.40 " 250 $721.28 $515.20 $824.32 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALGANCICLOVIR 450 MG (VALCYTE) TAB 1 TAB $121.84 250 $85.29 $60.92 $97.47 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALGANCICLOVIR 450 MG TAB (NF) 1 TAB $371.29 250 $259.90 $185.64 $297.03 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALGANCICLOVIR 50 MG/ML ORAL POW - NF 1 ML $35.01 250 $24.51 $17.51 $28.01 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALPROIC ACID 100 MG/ML INJ 5 ML VL 5 ML $72.60 250 $50.82 $36.30 $58.08 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALPROIC ACID 250 MG/5 ML ORAL SYG 5 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALPROIC ACID 50 MG/ML (DIL 1:2 D5W) 1 ML $14.64 250 $10.25 $7.32 $11.72 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALRUBICIN 40 MG/ML INJ (SDV) - NF 5 ML J9357 $369.20 636 $258.44 $184.60 $295.36 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALSARTAN 160 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALSARTAN 320 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALSARTAN 40 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VALSARTAN 80 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VANCOMYCIN 1000 MG INJ VL 20 ML J3370 $67.37 636 $47.16 $33.68 $53.89 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VANCOMYCIN 1000 MG/D5W 250 ML IVPB PREMADE KIT 250 ML J3370 $26.12 636 $18.29 $13.06 $20.90 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VANCOMYCIN 1000 MG/NS 250 ML IVPB 250 ML J3370 $26.12 636 $18.29 $13.06 $20.90 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VANCOMYCIN 125 MG CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VANCOMYCIN 50 MG/ML ORAL LIQUID 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VANCOMYCIN 500 MG / 0.9% NS 100 ML IVPB (NF) 100 ML J3370 $33.77 636 $23.64 $16.88 $27.01 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VANCOMYCIN 500 MG INJ VL J3370 $33.77 636 $23.64 $16.88 $27.01 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VANCOMYCIN 5000 MG INJ VL 50 ML J3370 $375.34 636 $262.74 $187.67 $300.27 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VANCOMYCIN RETENTION ENEMA 4MG/ML 1000 ML $101.14 250 $70.80 $50.57 $80.91 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VARDENAFIL 10 MG TAB 1 TAB $216.32 250 $151.43 $108.16 $173.06 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VARDENAFIL 2.5 MG TAB 1 TAB $216.32 250 $151.43 $108.16 $173.06 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VARDENAFIL 20 MG TAB 1 TAB $216.32 250 $151.43 $108.16 $173.06 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VARDENAFIL 5 MG TAB 1 TAB $216.32 250 $151.43 $108.16 $173.06 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VARICELLA VIRUS VACCINE INJ 0.5 ML 0.5 ML "$6,309.53 " 250 "$4,416.67 " "$3,154.77 " "$5,047.63 " 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VASOPRESSIN 20 UNITS INJ 1 ML VL 1 ML $891.98 250 $624.39 $445.99 $713.59 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VECURONIUM 10 MG INJ VL 10 ML $264.60 250 $185.22 $132.30 $211.68 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VECURONIUM 20 MG INJ 20 ML $420.00 250 $294.00 $210.00 $336.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VEDOLIZUMAB 300 MG (SDV) INJ - NF J3380 "$30,561.85 " 636 "$21,393.29 " "$15,280.92 " "$24,449.48 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VENLAFAXINE 100 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VENLAFAXINE 150 MG ER CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VENLAFAXINE 25 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VENLAFAXINE 37.5 MG ER CAP 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VENLAFAXINE 37.5 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VENLAFAXINE 50 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VENLAFAXINE 75 MG ER CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VENLAFAXINE 75 MG TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VERAPAMIL 10 MG/ML ORAL SYRG (PED) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VERAPAMIL 120 MG ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VERAPAMIL 120 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VERAPAMIL 180 MG ER TAB 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VERAPAMIL 2.5 MG/ML INJ 2 ML VL 2 ML $218.75 250 $153.13 $109.38 $175.00 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VERAPAMIL 240 MG ER TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VERAPAMIL 80 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VERTEPORFIN 15 MG INJ - NF J3396 "$7,180.78 " 636 "$5,026.55 " "$3,590.39 " "$5,744.63 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VINBLASTINE 10 MG VL 10MLVL 10 ML J9360 $141.60 636 $99.12 $70.80 $113.28 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VINCRISTINE 1 MG/ ML (SDV) INJ 2 ML 2 ML J9370 $116.24 636 $81.37 $58.12 $92.99 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VINCRISTINE 1 MG/ML (SDV) INJ 1 ML 1 ML J9370 $108.12 636 $75.68 $54.06 $86.49 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VINORELBINE 10 MG/ML INJ VL 1ML 1 ML J9390 $116.92 636 $81.84 $58.46 $93.53 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VINORELBINE 10 MG/ML INJ VL 5 ML 5 ML J9390 $184.61 636 $129.23 $92.31 $147.69 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VIT C/VIT E/ZINC/COPPER/OMEGA 3/LUTEIN (OCUVITE) 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VITAMIN A & D TOPICAL OINT 5 GM/PKT 1 APP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VITAMIN A & D TOPICAL OINT TUBE 1 APP $9.63 250 $6.74 $4.81 $7.70 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY "VITAMIN A 10,000 INTERNATIONAL UNITS (3000 MCG) CAPSULE - NF" 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VITAMIN E (TOCOPHERYL ACET) 15 INTL UNITS/0.3 ML ORAL SYG 0.3 ML $4.72 250 $3.31 $2.36 $3.78 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VITAMIN E 1000 IU CAP (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VORICONAZOLE 200 MG (SDV) INJ J3465 $175.00 636 $122.50 $87.50 $140.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VORICONAZOLE 200 MG TAB 1 TAB $63.71 250 $44.59 $31.85 $50.97 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VORICONAZOLE 200 MG TAB (NF) 1 TAB $15.48 250 $10.84 $7.74 $12.39 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VORICONAZOLE 40 MG/ML ORAL LIQUID - NF 1 ML $118.62 250 $83.03 $59.31 $94.90 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY VORICONAZOLE 50 MG TAB 1 TAB $17.48 250 $12.23 $8.74 $13.98 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY WARFARIN 1 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY WARFARIN 10 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY WARFARIN 2 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY WARFARIN 2.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY WARFARIN 4 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY WARFARIN 5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY WARFARIN 7.5 MG TAB UD 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY WATER FOR INJECTION 10 ML VL 10 ML A4216 $10.00 272 $7.00 $5.00 $8.00 65% 80% 50% 50% 65% 65% 65% PHARMACY ZAFIRLUKAST 20 MG TAB 1 TAB $4.40 250 $3.08 $2.20 $3.52 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZANAMIVIR 5 MG POWDER FOR ORAL INHALATION 1 INHALATION $49.56 250 $34.69 $24.78 $39.65 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZIDOVUDINE 10 MG/ML INJ 20 ML VL (AZT) 20 ML J3485 $122.60 636 $85.82 $61.30 $98.08 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZIDOVUDINE 10 MG/ML ORAL SYG (AZT) 1 ML $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZIDOVUDINE 100 MG CAP UD (AZT) 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZIDOVUDINE 300 MG TAB (AZT) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZINC CHLORIDE 1 MG/ML INJ 10 ML VL 1 ML $84.46 250 $59.12 $42.23 $67.57 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZINC GLUCONATE 50 MG TAB (NF) 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZINC OXIDE TOP 20% OINT 30 G TUBE 1 APP $24.25 250 $16.98 $12.13 $19.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZINC SULFATE 110 MG (25MG ELEMENTAL ZINC) TAB - NF 1 TAB $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZINC SULFATE 220 MG CAPSULE 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZINC SULFATE 5 MG/ML INJ 5ML VL 5 ML $205.10 250 $143.57 $102.55 $164.08 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZIPRASIDONE 20 MG (SDV) INJ J3486 "$2,188.80 " 636 "$1,532.16 " "$1,094.40 " "$1,751.04 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZIPRASIDONE 20 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZIPRASIDONE 40 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZIPRASIDONE 60 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZIPRASIDONE 80 MG CAP UD 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZOLEDRONIC ACID 4 MG INJ (SDV) 5 ML 5 ML J3489 $586.80 636 $410.76 $293.40 $469.44 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZOLEDRONIC ACID 5 MG/100 ML (SDV) 100 ML J3489 $481.25 636 $336.88 $240.63 $385.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZOLMITRIPTAN 2.5 MG TAB 1 TAB $28.34 250 $19.84 $14.17 $22.67 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZOLMITRIPTAN 5 MG TAB 1 TAB $32.80 250 $22.96 $16.40 $26.24 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZOLPIDEM 10 MG TAB UD - NF 1 TAB $18.89 250 $13.22 $9.44 $15.11 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZOLPIDEM 5 MG TAB UD - NF 1 TAB $8.00 250 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZONISAMIDE 100 MG CAP (NF) 1 CAP $7.68 250 $5.38 $3.84 $6.14 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZONISAMIDE 25 MG CAP (NF) 1 CAP $4.00 250 $2.80 $2.00 $3.20 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZOSTER VACCINE INACTIVATED (SHINGRIX) 0.5 ML INJ 0.5 ML $635.92 250 $445.15 $317.96 $508.74 65% 80% 50% 50% 65% 65% Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZZALBUMIN HUMAN 5% INJ 50 ML BTL 50 ML P9045 $45.91 636 $32.13 $22.95 $36.72 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount PHARMACY ZZFAMOTIDINE 10 MG/ML 20ML VL FOR TPN ONLY 1 ML $37.38 250 $26.17 $18.69 $29.90 65% 80% 50% 50% 65% 65% 65% PHARMACY ZZIRON DEXTRAN 10 MG/ML (DIL 1:5 NS) 1 ML J1750 $11.68 636 $8.18 $5.84 $9.35 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 42001081 PHYSICAL/OCCUPATIONAL THERAPY CANALITH REPOSITIONING EACH 95992 $105.00 420 $73.50 $52.50 $84.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000215 PHYSICAL/OCCUPATIONAL THERAPY OT COGNITIVE TRAIN-1ST 15 MIN 15 MINUTES 97129 $70.00 430 $49.00 $35.00 $56.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43009836 PHYSICAL/OCCUPATIONAL THERAPY OT COGNITIVE TRAIN-ADDL 15 MIN 15 MINUTES 97130 $70.00 430 $49.00 $35.00 $56.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000249 PHYSICAL/OCCUPATIONAL THERAPY OT DEBR NON-SELECTIVE W/O ANES EACH 97602 $495.00 430 $346.50 $247.50 $396.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000272 PHYSICAL/OCCUPATIONAL THERAPY OT E-STIM UNATTENDED 15 MINUTES 97014 $45.00 430 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43009794 PHYSICAL/OCCUPATIONAL THERAPY OT EVAL - HIGH COMPLEXITY EACH 97167 $332.00 430 $232.40 $166.00 $265.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43009778 PHYSICAL/OCCUPATIONAL THERAPY OT EVAL - LOW COMPLEXITY EACH 97165 $212.00 430 $148.40 $106.00 $169.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43009786 PHYSICAL/OCCUPATIONAL THERAPY OT EVAL - MODERATE COMPLEXITY EACH 97166 $265.00 430 $185.50 $132.50 $212.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000322 PHYSICAL/OCCUPATIONAL THERAPY OT EXERCISE THERAPY 15 MIN 15 MINUTES 97110 $83.00 430 $58.10 $41.50 $66.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000330 PHYSICAL/OCCUPATIONAL THERAPY OT FUNCTION CAPACITY 15 MIN EACH 97750 $85.00 430 $59.50 $42.50 $68.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000348 PHYSICAL/OCCUPATIONAL THERAPY OT GAIT TRAINING 15 MIN 15 MINUTES 97116 $72.00 430 $50.40 $36.00 $57.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000355 PHYSICAL/OCCUPATIONAL THERAPY OT HOT/PT/COLD PACK 15 MINUTES 97010 $63.00 430 $44.10 $31.50 $50.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000371 PHYSICAL/OCCUPATIONAL THERAPY OT MANUAL THRPY 15 MIN 15 MINUTES 97140 $76.00 430 $53.20 $38.00 $60.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000389 PHYSICAL/OCCUPATIONAL THERAPY OT MASSAGE 15 MIN 15 MINUTES 97124 $65.00 430 $45.50 $32.50 $52.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000439 PHYSICAL/OCCUPATIONAL THERAPY OT NEUROMUSCULAR RE-ED 15 MIN 15 MINUTES 97112 $107.00 430 $74.90 $53.50 $85.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000462 PHYSICAL/OCCUPATIONAL THERAPY OT PARAFFIN BATH THRPY EACH 97018 $24.00 430 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000520 PHYSICAL/OCCUPATIONAL THERAPY OT RE-EVALUATION EACH 97168 $126.00 434 $88.20 $63.00 $100.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000637 PHYSICAL/OCCUPATIONAL THERAPY OT TRACTION MECHANICAL EACH 97012 $42.00 430 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000629 PHYSICAL/OCCUPATIONAL THERAPY OT UNLSTD THRPY PROC 15 MIN 15 MINUTES 97139 $50.00 430 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000678 PHYSICAL/OCCUPATIONAL THERAPY OT VASOPNEUMATIC TREAT EACH 97016 $45.00 430 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000694 PHYSICAL/OCCUPATIONAL THERAPY OT WHIRLPOOL/FLUIDTHERAPY EACH 97022 $51.00 430 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000215 PHYSICAL/OCCUPATIONAL THERAPY PT COGNITIVE TRAIN-1ST 15 MIN EACH 97129 $70.00 430 $49.00 $35.00 $56.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43009836 PHYSICAL/OCCUPATIONAL THERAPY PT COGNITIVE TRAIN-ADDL 15 MIN EACH 97130 $70.00 430 $49.00 $35.00 $56.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000272 PHYSICAL/OCCUPATIONAL THERAPY PT E-STIM UNATTENDED EACH 97014 $45.00 430 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000322 PHYSICAL/OCCUPATIONAL THERAPY PT EXERCISE THERAPY 15 MIN EACH 97110 $83.00 430 $58.10 $41.50 $66.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000348 PHYSICAL/OCCUPATIONAL THERAPY PT GAIT TRAINING 15 MIN EACH 97116 $72.00 430 $50.40 $36.00 $57.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000355 PHYSICAL/OCCUPATIONAL THERAPY PT HOT/PT/COLD PACK EACH 97010 $63.00 430 $44.10 $31.50 $50.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000371 PHYSICAL/OCCUPATIONAL THERAPY PT MANUAL THRPY 15 MIN EACH 97140 $76.00 430 $53.20 $38.00 $60.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000389 PHYSICAL/OCCUPATIONAL THERAPY PT MASSAGE 15 MIN EACH 97124 $65.00 430 $45.50 $32.50 $52.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000439 PHYSICAL/OCCUPATIONAL THERAPY PT NEUROMUSCULAR RE-ED 15 MIN EACH 97112 $107.00 430 $74.90 $53.50 $85.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000462 PHYSICAL/OCCUPATIONAL THERAPY PT PARAFFIN BATH THRPY EACH 97018 $24.00 430 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000637 PHYSICAL/OCCUPATIONAL THERAPY PT TRACTION MECHANICAL EACH 97012 $42.00 430 $29.40 $21.00 $33.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000629 PHYSICAL/OCCUPATIONAL THERAPY PT UNLSTD THRPY PROC 15 MIN EACH 97139 $50.00 430 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000678 PHYSICAL/OCCUPATIONAL THERAPY PT VASOPNEUMATIC TREAT EACH 97016 $45.00 430 $31.50 $22.50 $36.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 43000694 PHYSICAL/OCCUPATIONAL THERAPY PT WHIRLPOOL/FLUIDTHERAPY EACH 97022 $51.00 430 $35.70 $25.50 $40.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000661 PHYSICAL/OCCUPATIONAL THERAPY PT/OT - DEVELOPMENTAL SCREENING EACH 96110 $244.00 918 $170.80 $122.00 $195.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 42000000 PHYSICAL/OCCUPATIONAL THERAPY PT/OT ADL 15 MIN EACH 97535 $56.00 420 $39.20 $28.00 $44.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000216 PHYSICAL/OCCUPATIONAL THERAPY PT/OT ASSISTIVE TECH ASSESS EACH 97755 $97.00 420 $67.90 $48.50 $77.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000232 PHYSICAL/OCCUPATIONAL THERAPY PT/OT C/O ORTH/PROST EST PT/OT 15 MI EACH 97763 $99.00 420 $69.30 $49.50 $79.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000257 PHYSICAL/OCCUPATIONAL THERAPY PT/OT COMM/WORK REINTEGRATE 15 M EACH 97537 $78.00 420 $54.60 $39.00 $62.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000265 PHYSICAL/OCCUPATIONAL THERAPY PT/OT CONTRAST BATH 15 MIN EACH 97034 $44.00 420 $30.80 $22.00 $35.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000307 PHYSICAL/OCCUPATIONAL THERAPY PT/OT ELECTROMAGNETIC TX FOR ULR EACH G0329 $24.00 420 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000315 PHYSICAL/OCCUPATIONAL THERAPY PT/OT E-STIM ATTENDED 15 MIN EACH 97032 $48.00 420 $33.60 $24.00 $38.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42001149 PHYSICAL/OCCUPATIONAL THERAPY PT/OT EVAL - HIGH COMPLEXITY EACH 97163 $341.00 420 $238.70 $170.50 $272.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42001123 PHYSICAL/OCCUPATIONAL THERAPY PT/OT EVAL - LOW COMPLEXITY EACH 97161 $218.00 420 $152.60 $109.00 $174.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42001131 PHYSICAL/OCCUPATIONAL THERAPY PT/OT EVAL - MODERATE COMPLEXITY EACH 97162 $273.00 420 $191.10 $136.50 $218.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000398 PHYSICAL/OCCUPATIONAL THERAPY PT/OT HUBBARD TANK 15 MIN EACH 97036 $74.00 420 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000406 PHYSICAL/OCCUPATIONAL THERAPY PT/OT IONTOPHORESIS 15 MIN EACH 97033 $71.00 420 $49.70 $35.50 $56.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000430 PHYSICAL/OCCUPATIONAL THERAPY PT/OT MUSCLE TEST BODY W/HANDS EACH 95834 $107.00 420 $74.90 $53.50 $85.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000448 PHYSICAL/OCCUPATIONAL THERAPY PT/OT MUSCLE TEST BODY W/O HANDS EACH 95833 $107.00 420 $74.90 $53.50 $85.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000455 PHYSICAL/OCCUPATIONAL THERAPY PT/OT MUSCLE TEST EXTREMITY/TRUNK EACH 95831 $107.00 420 $74.90 $53.50 $85.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000463 PHYSICAL/OCCUPATIONAL THERAPY PT/OT MUSCLE TEST HAND EACH 95832 $107.00 420 $74.90 $53.50 $85.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000513 PHYSICAL/OCCUPATIONAL THERAPY PT/OT ORTHOTIC MNGMNT/FIT/TRAN 15 EACH 97760 $95.00 420 $66.50 $47.50 $76.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000570 PHYSICAL/OCCUPATIONAL THERAPY PT/OT PROSTHETIC TRAINING EA 15 M EACH 97761 $84.00 420 $58.80 $42.00 $67.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000588 PHYSICAL/OCCUPATIONAL THERAPY PT/OT RE-EVALUATION EACH 97164 $110.00 424 $77.00 $55.00 $88.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000596 PHYSICAL/OCCUPATIONAL THERAPY PT/OT ROM TEST EA EXTREM/TRNK SEC EACH 95851 $24.00 420 $16.80 $12.00 $19.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000604 PHYSICAL/OCCUPATIONAL THERAPY PT/OT ROM TESTING HAND EACH 95852 $17.00 420 $11.90 $8.50 $13.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000646 PHYSICAL/OCCUPATIONAL THERAPY PT/OT SENSORY TECHNIQUE 15 MIN EACH 97533 $76.00 420 $53.20 $38.00 $60.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000679 PHYSICAL/OCCUPATIONAL THERAPY PT/OT THERAPEUTIC ACTIVITY 15 MIN EACH 97530 $83.00 420 $58.10 $41.50 $66.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000687 PHYSICAL/OCCUPATIONAL THERAPY PT/OT THERAPEUTIC GROUP EACH 97150 $52.00 423 $36.40 $26.00 $41.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000703 PHYSICAL/OCCUPATIONAL THERAPY PT/OT ULTRASOUND 15 MIN EACH 97035 $34.00 420 $23.80 $17.00 $27.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000711 PHYSICAL/OCCUPATIONAL THERAPY PT/OT UNLISTED PROCEDURE EACH 97799 $50.00 420 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42000729 PHYSICAL/OCCUPATIONAL THERAPY PT/OT UNLSTD MODALITY 15 MIN EACH 97039 $50.00 420 $35.00 $25.00 $40.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42001073 PHYSICAL/OCCUPATIONAL THERAPY PT/OT WHEELCHAIR MANAGE 15 MIN EACH 97542 $79.00 420 $55.30 $39.50 $63.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 42001172 PHYSICAL/OCCUPATIONAL THERAPY PT/OT-DEVELOP TESTING ADD 30 MIN EACH 96113 $111.00 918 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 42000653 PHYSICAL/OCCUPATIONAL THERAPY PT/OT-DEVELOPMNTAL TESTING 1ST HR EACH 96112 $387.00 918 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205800 PHYSICIAN FEE - ANESTHESIA PF-ANES DRG/ASPIR CRV/THRC 15 MINUTES 01937 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205818 PHYSICIAN FEE - ANESTHESIA PF-ANES DRG/ASPIR LMBR/SAC 15 MINUTES 01938 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204704 PHYSICIAN FEE - ANESTHESIA PF-ANES DX SHOULDER ARTHROSCPY - 1ST 15 MINUTES 15 MINUTES 01622 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204704 PHYSICIAN FEE - ANESTHESIA PF-ANES DX SHOULDER ARTHROSCPY - EACH ADDL 15 MINUTES 15 MINUTES 01622 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205727 PHYSICIAN FEE - ANESTHESIA PF-ANES LWR INTST NDSC NOS - 1ST 15 MINUTES 15 MINUTES 00811 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205727 PHYSICIAN FEE - ANESTHESIA PF-ANES LWR INTST NDSC NOS - EACH ADDL 15 MINUTES 15 MINUTES 00811 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205735 PHYSICIAN FEE - ANESTHESIA PF-ANES LWR INTST SCR COLSC - 1ST 15 MINUTES 15 MINUTES 00812 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205735 PHYSICIAN FEE - ANESTHESIA PF-ANES LWR INTST SCR COLSC - EACH ADDL 15 MINUTES 15 MINUTES 00812 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203375 PHYSICIAN FEE - ANESTHESIA PF-ANES MEDIASCPY & DX THORSCP - 1ST 15 MINUTES 15 MINUTES 00528 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203375 PHYSICIAN FEE - ANESTHESIA PF-ANES MEDIASCPY & DX THORSCP - EACH ADDL 15 MINUTES 15 MINUTES 00528 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203383 PHYSICIAN FEE - ANESTHESIA PF-ANES MEDSCPY&THORSCP 1 LUNG - 1ST 15 MINUTES 15 MINUTES 00529 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203383 PHYSICIAN FEE - ANESTHESIA PF-ANES MEDSCPY&THORSCP 1 LUNG - EACH ADDL 15 MINUTES 15 MINUTES 00529 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203953 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMEN VESSEL SUR - 1ST 15 MINUTES 15 MINUTES 00880 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203953 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMEN VESSEL SUR - EACH ADDL 15 MINUTES 15 MINUTES 00880 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203631 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMINAL WALL SUR - 1ST 15 MINUTES 15 MINUTES 00700 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203649 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMINAL WALL SUR - 1ST 15 MINUTES 15 MINUTES 00730 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203755 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMINAL WALL SUR - 1ST 15 MINUTES 15 MINUTES 00800 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203789 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMINAL WALL SUR - 1ST 15 MINUTES 15 MINUTES 00820 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203631 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMINAL WALL SUR - EACH ADDL 15 MINUTES 15 MINUTES 00700 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203649 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMINAL WALL SUR - EACH ADDL 15 MINUTES 15 MINUTES 00730 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203755 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMINAL WALL SUR - EACH ADDL 15 MINUTES 15 MINUTES 00800 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203789 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ABDOMINAL WALL SUR - EACH ADDL 15 MINUTES 15 MINUTES 00820 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204589 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ACHILLES TENDON - 1ST 15 MINUTES 15 MINUTES 01472 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204589 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ACHILLES TENDON - EACH ADDL 15 MINUTES 15 MINUTES 01472 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203847 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN AMNIOCENTESIS - 1ST 15 MINUTES 15 MINUTES 00842 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203847 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN AMNIOCENTESIS - EACH ADDL 15 MINUTES 15 MINUTES 00842 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204241 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN AMPUTATE AT PELVIS - 1ST 15 MINUTES 15 MINUTES 01140 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204241 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN AMPUTATE AT PELVIS - EACH ADDL 15 MINUTES 15 MINUTES 01140 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204514 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN AMPUTATION AT KNEE - 1ST 15 MINUTES 15 MINUTES 01404 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204514 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN AMPUTATION AT KNEE - EACH ADDL 15 MINUTES 15 MINUTES 01404 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204373 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN AMPUTATION FEMUR - 1ST 15 MINUTES 15 MINUTES 01232 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204373 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN AMPUTATION FEMUR - EACH ADDL 15 MINUTES 15 MINUTES 01232 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204639 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ANKLE REPLACEMENT - 1ST 15 MINUTES 15 MINUTES 01486 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204639 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ANKLE REPLACEMENT - EACH ADDL 15 MINUTES 15 MINUTES 01486 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203979 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ANORECTAL SURGERY - 1ST 15 MINUTES 15 MINUTES 00902 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203979 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ANORECTAL SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00902 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205198 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ANTEPARTUM MANIPUL - 1ST 15 MINUTES 15 MINUTES 01958 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205198 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ANTEPARTUM MANIPUL - EACH ADDL 15 MINUTES 15 MINUTES 01958 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204761 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ARM-LEG VESSEL SUR - 1ST 15 MINUTES 15 MINUTES 01656 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204761 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ARM-LEG VESSEL SUR - EACH ADDL 15 MINUTES 15 MINUTES 01656 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204308 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ARTHROSCOPY OF HIP - 1ST 15 MINUTES 15 MINUTES 01202 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204308 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ARTHROSCOPY OF HIP - EACH ADDL 15 MINUTES 15 MINUTES 01202 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204829 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BICEPS TENDON REP - 1ST 15 MINUTES 15 MINUTES 01716 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204829 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BICEPS TENDON REP - EACH ADDL 15 MINUTES 15 MINUTES 01716 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203086 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BIOPSY OF NOSE - 1ST 15 MINUTES 15 MINUTES 00164 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203086 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BIOPSY OF NOSE - EACH ADDL 15 MINUTES 15 MINUTES 00164 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203235 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BIOPSY OF THYROID - 1ST 15 MINUTES 15 MINUTES 00322 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203235 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BIOPSY OF THYROID - EACH ADDL 15 MINUTES 15 MINUTES 00322 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203920 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLADDER STONE SURG - 1ST 15 MINUTES 15 MINUTES 00870 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203920 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLADDER STONE SURG - EACH ADDL 15 MINUTES 15 MINUTES 00870 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204001 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLADDER SURGERY - 1ST 15 MINUTES 15 MINUTES 00910 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204001 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLADDER SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00910 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204019 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLADDER TUMOR SURG - 1ST 15 MINUTES 15 MINUTES 00912 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204019 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLADDER TUMOR SURG - EACH ADDL 15 MINUTES 15 MINUTES 00912 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204035 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLEEDING CONTROL - 1ST 15 MINUTES 15 MINUTES 00916 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204035 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLEEDING CONTROL - EACH ADDL 15 MINUTES 15 MINUTES 00916 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203698 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLOOD VESSEL REP - 1ST 15 MINUTES 15 MINUTES 00770 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203698 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BLOOD VESSEL REP - EACH ADDL 15 MINUTES 15 MINUTES 00770 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204233 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BODY CAST PROC - 1ST 15 MINUTES 15 MINUTES 01130 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204233 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BODY CAST PROC - EACH ADDL 15 MINUTES 15 MINUTES 01130 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204217 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BONE ASPIRATE/BX - 1ST 15 MINUTES 15 MINUTES 01112 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204217 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BONE ASPIRATE/BX - EACH ADDL 15 MINUTES 15 MINUTES 01112 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205164 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BURN < 4 PERCENT - 1ST 15 MINUTES 15 MINUTES 01951 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205164 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BURN < 4 PERCENT - EACH ADDL 15 MINUTES 15 MINUTES 01951 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205172 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BURN 4-9 PERCENT - 1ST 15 MINUTES 15 MINUTES 01952 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205172 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BURN 4-9 PERCENT - EACH ADDL 15 MINUTES 15 MINUTES 01952 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205180 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BURN EA 9 PERCENT - 1ST 15 MINUTES 15 MINUTES 01953 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205180 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN BURN EA 9 PERCENT - EACH ADDL 15 MINUTES 15 MINUTES 01953 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203524 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CABG W/O PUMP - 1ST 15 MINUTES 15 MINUTES 00566 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203524 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CABG W/O PUMP - EACH ADDL 15 MINUTES 15 MINUTES 00566 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203417 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CARDIAC ELECTROPHY - 1ST 15 MINUTES 15 MINUTES 00537 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203417 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CARDIAC ELECTROPHY - EACH ADDL 15 MINUTES 15 MINUTES 00537 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203409 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CARDIOVERTER/DEFIB - 1ST 15 MINUTES 15 MINUTES 00534 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203409 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CARDIOVERTER/DEFIB - EACH ADDL 15 MINUTES 15 MINUTES 00534 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205065 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CAT OR MRI SCAN - 1ST 15 MINUTES 15 MINUTES 01922 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205065 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CAT OR MRI SCAN - EACH ADDL 15 MINUTES 15 MINUTES 01922 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205057 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CATHETERIZE HEART - 1ST 15 MINUTES 15 MINUTES 01920 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205057 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CATHETERIZE HEART - EACH ADDL 15 MINUTES 15 MINUTES 01920 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203367 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CHEST DRAINAGE - 1ST 15 MINUTES 15 MINUTES 00524 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203367 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CHEST DRAINAGE - EACH ADDL 15 MINUTES 15 MINUTES 00524 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203359 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CHEST PROCEDURE - 1ST 15 MINUTES 15 MINUTES 00520 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203359 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CHEST PROCEDURE - EACH ADDL 15 MINUTES 15 MINUTES 00520 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203334 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CHEST WALL REPAIR - 1ST 15 MINUTES 15 MINUTES 00472 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203334 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CHEST WALL REPAIR - EACH ADDL 15 MINUTES 15 MINUTES 00472 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203318 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN COLLAR BONE BIOPSY - 1ST 15 MINUTES 15 MINUTES 00454 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203318 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN COLLAR BONE BIOPSY - EACH ADDL 15 MINUTES 15 MINUTES 00454 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203151 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CRAN SURG HEMOTOMA - 1ST 15 MINUTES 15 MINUTES 00211 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203151 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CRAN SURG HEMOTOMA - EACH ADDL 15 MINUTES 15 MINUTES 00211 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203144 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CRANIAL SURG NOS - 1ST 15 MINUTES 15 MINUTES 00210 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203144 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CRANIAL SURG NOS - EACH ADDL 15 MINUTES 15 MINUTES 00210 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205214 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CS DELIVERY - 1ST 15 MINUTES 15 MINUTES 01961 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205214 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN CS DELIVERY - EACH ADDL 15 MINUTES 15 MINUTES 01961 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205040 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN DX ARTERIOGRAPHY - 1ST 15 MINUTES 15 MINUTES 01916 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205040 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN DX ARTERIOGRAPHY - EACH ADDL 15 MINUTES 15 MINUTES 01916 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204845 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN DX ELBOW ARTHRO - 1ST 15 MINUTES 15 MINUTES 01732 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204845 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN DX ELBOW ARTHRO - EACH ADDL 15 MINUTES 15 MINUTES 01732 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204464 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN DX KNEE ARTHROSCPY - 1ST 15 MINUTES 15 MINUTES 01382 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204464 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN DX KNEE ARTHROSCPY - EACH ADDL 15 MINUTES 15 MINUTES 01382 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204951 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN DX WRIST ARTHROSC - 1ST 15 MINUTES 15 MINUTES 01829 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204951 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN DX WRIST ARTHROSC - EACH ADDL 15 MINUTES 15 MINUTES 01829 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204803 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ELBOW AREA SURGERY - 1ST 15 MINUTES 15 MINUTES 01710 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204803 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ELBOW AREA SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01710 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204886 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ELBOW REPLACEMENT - 1ST 15 MINUTES 15 MINUTES 01760 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204886 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ELBOW REPLACEMENT - EACH ADDL 15 MINUTES 15 MINUTES 01760 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203011 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ELECTROSHOCK - 1ST 15 MINUTES 15 MINUTES 00104 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203011 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ELECTROSHOCK - EACH ADDL 15 MINUTES 15 MINUTES 00104 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205222 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN EMER HYSTERECTOMY - 1ST 15 MINUTES 15 MINUTES 01962 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205222 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN EMER HYSTERECTOMY - EACH ADDL 15 MINUTES 15 MINUTES 01962 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203342 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ESOPHAGEAL SURGERY - 1ST 15 MINUTES 15 MINUTES 00500 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203342 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ESOPHAGEAL SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00500 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203060 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN EYE EXAM - 1ST 15 MINUTES 15 MINUTES 00148 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203060 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN EYE EXAM - EACH ADDL 15 MINUTES 15 MINUTES 00148 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203128 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FACE/SKULL BONE - 1ST 15 MINUTES 15 MINUTES 00190 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203128 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FACE/SKULL BONE - EACH ADDL 15 MINUTES 15 MINUTES 00190 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203136 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FACIAL BONE SURG - 1ST 15 MINUTES 15 MINUTES 00192 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203136 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FACIAL BONE SURG - EACH ADDL 15 MINUTES 15 MINUTES 00192 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203763 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FAT LAYER REMOVAL - 1ST 15 MINUTES 15 MINUTES 00802 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203763 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FAT LAYER REMOVAL - EACH ADDL 15 MINUTES 15 MINUTES 00802 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204415 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FEMORAL ARTERY SUR - 1ST 15 MINUTES 15 MINUTES 01272 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204415 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FEMORAL ARTERY SUR - EACH ADDL 15 MINUTES 15 MINUTES 01272 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204423 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FEMORAL EMBOLECTMY - 1ST 15 MINUTES 15 MINUTES 01274 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204423 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FEMORAL EMBOLECTMY - EACH ADDL 15 MINUTES 15 MINUTES 01274 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203730 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FOR LIVER TRANSPL - 1ST 15 MINUTES 15 MINUTES 00796 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203730 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FOR LIVER TRANSPL - EACH ADDL 15 MINUTES 15 MINUTES 00796 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204738 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FOREQUARTER AMPUT - 1ST 15 MINUTES 15 MINUTES 01636 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204738 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FOREQUARTER AMPUT - EACH ADDL 15 MINUTES 15 MINUTES 01636 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204282 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FX REPAIR PELVIS - 1ST 15 MINUTES 15 MINUTES 01173 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204282 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN FX REPAIR PELVIS - EACH ADDL 15 MINUTES 15 MINUTES 01173 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204050 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN GENITALIA SURGERY - 1ST 15 MINUTES 15 MINUTES 00920 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204050 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN GENITALIA SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00920 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203219 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEAD NERVE SURGERY - 1ST 15 MINUTES 15 MINUTES 00222 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203219 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEAD NERVE SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00222 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203185 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEAD VESSEL SURG - 1ST 15 MINUTES 15 MINUTES 00216 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203185 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEAD VESSEL SURG - EACH ADDL 15 MINUTES 15 MINUTES 00216 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203227 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEAD/NECK/PTRUNK - 1ST 15 MINUTES 15 MINUTES 00300 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203227 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEAD/NECK/PTRUNK - EACH ADDL 15 MINUTES 15 MINUTES 00300 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203292 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART RHYTHM - 1ST 15 MINUTES 15 MINUTES 00410 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203292 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART RHYTHM - EACH ADDL 15 MINUTES 15 MINUTES 00410 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203516 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART SUR W/ARREST - 1ST 15 MINUTES 15 MINUTES 00563 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203516 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART SUR W/ARREST - EACH ADDL 15 MINUTES 15 MINUTES 00563 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203490 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART SURG <1 YR - 1ST 15 MINUTES 15 MINUTES 00561 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203490 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART SURG <1 YR - EACH ADDL 15 MINUTES 15 MINUTES 00561 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203482 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART SURG WO PUMP - 1ST 15 MINUTES 15 MINUTES 00560 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203482 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART SURG WO PUMP - EACH ADDL 15 MINUTES 15 MINUTES 00560 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203532 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART/LUNG TRANSPL - 1ST 15 MINUTES 15 MINUTES 00580 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203532 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEART/LUNG TRANSPL - EACH ADDL 15 MINUTES 15 MINUTES 00580 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203714 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEMOR/EXCISE LIVER - 1ST 15 MINUTES 15 MINUTES 00792 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203714 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HEMOR/EXCISE LIVER - EACH ADDL 15 MINUTES 15 MINUTES 00792 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203821 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HERNIA REP PREEMIE - 1ST 15 MINUTES 15 MINUTES 00836 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203821 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HERNIA REP PREEMIE - EACH ADDL 15 MINUTES 15 MINUTES 00836 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203813 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HERNIA REPAIR<1 YR - 1ST 15 MINUTES 15 MINUTES 00834 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203813 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HERNIA REPAIR<1 YR - EACH ADDL 15 MINUTES 15 MINUTES 00834 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204332 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HIP ARTHROPLASTY - 1ST 15 MINUTES 15 MINUTES 01214 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204332 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HIP ARTHROPLASTY - EACH ADDL 15 MINUTES 15 MINUTES 01214 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204324 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HIP DISARTICULATN - 1ST 15 MINUTES 15 MINUTES 01212 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204324 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HIP DISARTICULATN - EACH ADDL 15 MINUTES 15 MINUTES 01212 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204290 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HIP JOINT PROC - 1ST 15 MINUTES 15 MINUTES 01200 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204290 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HIP JOINT PROC - EACH ADDL 15 MINUTES 15 MINUTES 01200 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204316 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HIP JOINT SURGERY - 1ST 15 MINUTES 15 MINUTES 01210 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204316 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HIP JOINT SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01210 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203508 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HRT SRG W/PMP 1+ - 1ST 15 MINUTES 15 MINUTES 00562 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203508 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HRT SRG W/PMP 1+ - EACH ADDL 15 MINUTES 15 MINUTES 00562 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204878 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HUMERAL LESION SUR - 1ST 15 MINUTES 15 MINUTES 01758 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204878 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HUMERAL LESION SUR - EACH ADDL 15 MINUTES 15 MINUTES 01758 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204860 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HUMERUS REPAIR - 1ST 15 MINUTES 15 MINUTES 01744 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204860 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HUMERUS REPAIR - EACH ADDL 15 MINUTES 15 MINUTES 01744 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203862 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HYSTERECTOMY - 1ST 15 MINUTES 15 MINUTES 00846 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203862 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HYSTERECTOMY - EACH ADDL 15 MINUTES 15 MINUTES 00846 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204209 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HYSTEROSCOPE/GRAPH - 1ST 15 MINUTES 15 MINUTES 00952 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204209 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN HYSTEROSCOPE/GRAPH - EACH ADDL 15 MINUTES 15 MINUTES 00952 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205230 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN INC/MISSED AB PROC - 1ST 15 MINUTES 15 MINUTES 01965 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205230 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN INC/MISSED AB PROC - EACH ADDL 15 MINUTES 15 MINUTES 01965 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205248 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN INDUCED AB PROC - 1ST 15 MINUTES 15 MINUTES 01966 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205248 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN INDUCED AB PROC - EACH ADDL 15 MINUTES 15 MINUTES 01966 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204142 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN INSERT PENIS DEV - 1ST 15 MINUTES 15 MINUTES 00938 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204142 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN INSERT PENIS DEV - EACH ADDL 15 MINUTES 15 MINUTES 00938 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203201 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN INTRCRN NERVE - 1ST 15 MINUTES 15 MINUTES 00220 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203201 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN INTRCRN NERVE - EACH ADDL 15 MINUTES 15 MINUTES 00220 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203938 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KIDNEY STONE DESTR - 1ST 15 MINUTES 15 MINUTES 00872 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203946 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KIDNEY STONE DESTR - 1ST 15 MINUTES 15 MINUTES 00873 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203938 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KIDNEY STONE DESTR - EACH ADDL 15 MINUTES 15 MINUTES 00872 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203946 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KIDNEY STONE DESTR - EACH ADDL 15 MINUTES 15 MINUTES 00873 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203912 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KIDNEY TRANSPLANT - 1ST 15 MINUTES 15 MINUTES 00868 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203912 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KIDNEY TRANSPLANT - EACH ADDL 15 MINUTES 15 MINUTES 00868 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203888 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KIDNEY/URETER SURG - 1ST 15 MINUTES 15 MINUTES 00862 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203888 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KIDNEY/URETER SURG - EACH ADDL 15 MINUTES 15 MINUTES 00862 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204449 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE AREA PROC - 1ST 15 MINUTES 15 MINUTES 01340 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204472 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE AREA PROC - 1ST 15 MINUTES 15 MINUTES 01390 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204449 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE AREA PROC - EACH ADDL 15 MINUTES 15 MINUTES 01340 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204472 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE AREA PROC - EACH ADDL 15 MINUTES 15 MINUTES 01390 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204431 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE AREA SURGERY - 1ST 15 MINUTES 15 MINUTES 01320 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204480 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE AREA SURGERY - 1ST 15 MINUTES 15 MINUTES 01392 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204431 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE AREA SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01320 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204480 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE AREA SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01392 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204548 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE ARTERIES SURG - 1ST 15 MINUTES 15 MINUTES 01440 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204548 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE ARTERIES SURG - EACH ADDL 15 MINUTES 15 MINUTES 01440 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204555 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE ARTERY REPAIR - 1ST 15 MINUTES 15 MINUTES 01444 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204555 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE ARTERY REPAIR - EACH ADDL 15 MINUTES 15 MINUTES 01444 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204506 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE ARTHROPLASTY - 1ST 15 MINUTES 15 MINUTES 01402 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204506 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE ARTHROPLASTY - EACH ADDL 15 MINUTES 15 MINUTES 01402 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204522 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE JOINT CASTING - 1ST 15 MINUTES 15 MINUTES 01420 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204522 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE JOINT CASTING - EACH ADDL 15 MINUTES 15 MINUTES 01420 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204456 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE JOINT PROC - 1ST 15 MINUTES 15 MINUTES 01380 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204456 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE JOINT PROC - EACH ADDL 15 MINUTES 15 MINUTES 01380 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204498 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE JOINT SURGERY - 1ST 15 MINUTES 15 MINUTES 01400 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204498 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE JOINT SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01400 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204530 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE VESSEL SURG - 1ST 15 MINUTES 15 MINUTES 01432 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204530 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN KNEE VESSEL SURG - EACH ADDL 15 MINUTES 15 MINUTES 01432 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203243 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LARYNX/TRACH<1 YR - 1ST 15 MINUTES 15 MINUTES 00326 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203243 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LARYNX/TRACH<1 YR - EACH ADDL 15 MINUTES 15 MINUTES 00326 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204647 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LEG ARTERIES SURG - 1ST 15 MINUTES 15 MINUTES 01500 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204647 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LEG ARTERIES SURG - EACH ADDL 15 MINUTES 15 MINUTES 01500 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203045 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LENS SURGERY - 1ST 15 MINUTES 15 MINUTES 00142 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203045 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LENS SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00142 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205032 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM CASTING - 1ST 15 MINUTES 15 MINUTES 01860 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205032 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM CASTING - EACH ADDL 15 MINUTES 15 MINUTES 01860 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204944 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM PROC - 1ST 15 MINUTES 15 MINUTES 01820 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204944 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM PROC - EACH ADDL 15 MINUTES 15 MINUTES 01820 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204936 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM SURGERY - 1ST 15 MINUTES 15 MINUTES 01810 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204969 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM SURGERY - 1ST 15 MINUTES 15 MINUTES 01830 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204936 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01810 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204969 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01830 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205016 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM VEIN SUR - 1ST 15 MINUTES 15 MINUTES 01850 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205016 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER ARM VEIN SUR - EACH ADDL 15 MINUTES 15 MINUTES 01850 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204605 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG BONE SUR - 1ST 15 MINUTES 15 MINUTES 01480 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204605 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG BONE SUR - EACH ADDL 15 MINUTES 15 MINUTES 01480 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204563 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG PROC - 1ST 15 MINUTES 15 MINUTES 01462 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204563 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG PROC - EACH ADDL 15 MINUTES 15 MINUTES 01462 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204621 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG REVISION - 1ST 15 MINUTES 15 MINUTES 01484 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204621 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG REVISION - EACH ADDL 15 MINUTES 15 MINUTES 01484 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204571 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG SURGERY - 1ST 15 MINUTES 15 MINUTES 01470 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204597 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG SURGERY - 1ST 15 MINUTES 15 MINUTES 01474 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204571 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01470 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204597 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01474 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204662 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG VEIN SUR - 1ST 15 MINUTES 15 MINUTES 01520 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204670 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG VEIN SUR - 1ST 15 MINUTES 15 MINUTES 01522 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204662 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG VEIN SUR - EACH ADDL 15 MINUTES 15 MINUTES 01520 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204670 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LOWER LEG VEIN SUR - EACH ADDL 15 MINUTES 15 MINUTES 01522 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203607 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LUMBAR PUNCTURE - 1ST 15 MINUTES 15 MINUTES 00635 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203607 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LUMBAR PUNCTURE - EACH ADDL 15 MINUTES 15 MINUTES 00635 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203458 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LUNG CHEST WALL - 1ST 15 MINUTES 15 MINUTES 00546 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203458 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LUNG CHEST WALL - EACH ADDL 15 MINUTES 15 MINUTES 00546 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204985 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LWR ARM ARTERY SUR - 1ST 15 MINUTES 15 MINUTES 01840 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204985 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LWR ARM ARTERY SUR - EACH ADDL 15 MINUTES 15 MINUTES 01840 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204993 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LWR ARM EMBOLECTMY - 1ST 15 MINUTES 15 MINUTES 01842 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204993 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LWR ARM EMBOLECTMY - EACH ADDL 15 MINUTES 15 MINUTES 01842 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205024 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LWR ARM VEIN REP - 1ST 15 MINUTES 15 MINUTES 01852 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205024 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LWR ARM VEIN REP - EACH ADDL 15 MINUTES 15 MINUTES 01852 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204654 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LWR LEG EMBOLECTMY - 1ST 15 MINUTES 15 MINUTES 01502 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204654 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN LWR LEG EMBOLECTMY - EACH ADDL 15 MINUTES 15 MINUTES 01502 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203961 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN MJR VEIN LIGATION - 1ST 15 MINUTES 15 MINUTES 00882 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203961 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN MJR VEIN LIGATION - EACH ADDL 15 MINUTES 15 MINUTES 00882 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205289 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN N BLOCK/INJ PRONE - 1ST 15 MINUTES 15 MINUTES 01992 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205289 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN N BLOCK/INJ PRONE - EACH ADDL 15 MINUTES 15 MINUTES 01992 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203250 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN NECK VESSEL SURG - 1ST 15 MINUTES 15 MINUTES 00350 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203250 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN NECK VESSEL SURG - EACH ADDL 15 MINUTES 15 MINUTES 00350 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205271 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN NERVE BLOCK/INJ - 1ST 15 MINUTES 15 MINUTES 01991 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205271 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN NERVE BLOCK/INJ - EACH ADDL 15 MINUTES 15 MINUTES 01991 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203078 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN NOSE/SINUS SURGERY - 1ST 15 MINUTES 15 MINUTES 00160 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203078 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN NOSE/SINUS SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00160 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203433 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ONE LUNG VENTILAT - 1ST 15 MINUTES 15 MINUTES 00541 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203433 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN ONE LUNG VENTILAT - EACH ADDL 15 MINUTES 15 MINUTES 00541 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203391 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PACEMAKER INSERT - 1ST 15 MINUTES 15 MINUTES 00530 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203391 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PACEMAKER INSERT - EACH ADDL 15 MINUTES 15 MINUTES 00530 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203722 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PANCREAS REMOVAL - 1ST 15 MINUTES 15 MINUTES 00794 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203722 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PANCREAS REMOVAL - EACH ADDL 15 MINUTES 15 MINUTES 00794 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203870 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIC ORGAN SURG - 1ST 15 MINUTES 15 MINUTES 00848 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203870 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIC ORGAN SURG - EACH ADDL 15 MINUTES 15 MINUTES 00848 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204258 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIC TUMOR SURG - 1ST 15 MINUTES 15 MINUTES 01150 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204258 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIC TUMOR SURG - EACH ADDL 15 MINUTES 15 MINUTES 01150 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204266 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIS PROCEDURE - 1ST 15 MINUTES 15 MINUTES 01160 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204266 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIS PROCEDURE - EACH ADDL 15 MINUTES 15 MINUTES 01160 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203854 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIS SURGERY - 1ST 15 MINUTES 15 MINUTES 00844 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204225 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIS SURGERY - 1ST 15 MINUTES 15 MINUTES 01120 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204274 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIS SURGERY - 1ST 15 MINUTES 15 MINUTES 01170 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203854 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIS SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00844 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204225 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIS SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01120 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204274 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PELVIS SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01170 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204126 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PENIS NODES REM0VL - 1ST 15 MINUTES 15 MINUTES 00934 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204126 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PENIS NODES REM0VL - EACH ADDL 15 MINUTES 15 MINUTES 00934 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204134 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PENIS NODES REMOVL - 1ST 15 MINUTES 15 MINUTES 00936 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204134 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PENIS NODES REMOVL - EACH ADDL 15 MINUTES 15 MINUTES 00936 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203102 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PHARYNGEAL SURGERY - 1ST 15 MINUTES 15 MINUTES 00174 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203110 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PHARYNGEAL SURGERY - 1ST 15 MINUTES 15 MINUTES 00176 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203102 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PHARYNGEAL SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00174 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203110 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PHARYNGEAL SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00176 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204357 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PROCEDURE ON FEMUR - 1ST 15 MINUTES 15 MINUTES 01220 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204357 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PROCEDURE ON FEMUR - EACH ADDL 15 MINUTES 15 MINUTES 01220 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203094 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PROCEDURE ON MOUTH - 1ST 15 MINUTES 15 MINUTES 00170 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203094 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PROCEDURE ON MOUTH - EACH ADDL 15 MINUTES 15 MINUTES 00170 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203037 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PROCEDURES ON EYE - 1ST 15 MINUTES 15 MINUTES 00140 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203037 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN PROCEDURES ON EYE - EACH ADDL 15 MINUTES 15 MINUTES 00140 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204381 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN RADICAL FEMUR SURG - 1ST 15 MINUTES 15 MINUTES 01234 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204381 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN RADICAL FEMUR SURG - EACH ADDL 15 MINUTES 15 MINUTES 01234 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204613 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN RADICAL LEG SURG - 1ST 15 MINUTES 15 MINUTES 01482 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204613 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN RADICAL LEG SURG - EACH ADDL 15 MINUTES 15 MINUTES 01482 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203904 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF ADRENAL - 1ST 15 MINUTES 15 MINUTES 00866 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203904 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF ADRENAL - EACH ADDL 15 MINUTES 15 MINUTES 00866 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203599 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF NERVES - 1ST 15 MINUTES 15 MINUTES 00632 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203599 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF NERVES - EACH ADDL 15 MINUTES 15 MINUTES 00632 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203326 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF RIB - 1ST 15 MINUTES 15 MINUTES 00470 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203326 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF RIB - EACH ADDL 15 MINUTES 15 MINUTES 00470 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204092 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF TESTIS - 1ST 15 MINUTES 15 MINUTES 00926 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204100 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF TESTIS - 1ST 15 MINUTES 15 MINUTES 00928 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204092 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF TESTIS - EACH ADDL 15 MINUTES 15 MINUTES 00926 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204100 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF TESTIS - EACH ADDL 15 MINUTES 15 MINUTES 00928 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203987 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF VULVA - 1ST 15 MINUTES 15 MINUTES 00906 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203987 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL OF VULVA - EACH ADDL 15 MINUTES 15 MINUTES 00906 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203896 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL PROSTATE - 1ST 15 MINUTES 15 MINUTES 00865 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203995 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL PROSTATE - 1ST 15 MINUTES 15 MINUTES 00908 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204027 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL PROSTATE - 1ST 15 MINUTES 15 MINUTES 00914 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203896 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL PROSTATE - EACH ADDL 15 MINUTES 15 MINUTES 00865 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203995 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL PROSTATE - EACH ADDL 15 MINUTES 15 MINUTES 00908 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204027 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REMOVAL PROSTATE - EACH ADDL 15 MINUTES 15 MINUTES 00914 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204183 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF CERVIX - 1ST 15 MINUTES 15 MINUTES 00948 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204183 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF CERVIX - EACH ADDL 15 MINUTES 15 MINUTES 00948 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203664 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - 1ST 15 MINUTES 15 MINUTES 00750 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203672 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - 1ST 15 MINUTES 15 MINUTES 00752 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203680 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - 1ST 15 MINUTES 15 MINUTES 00754 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203797 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - 1ST 15 MINUTES 15 MINUTES 00830 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203805 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - 1ST 15 MINUTES 15 MINUTES 00832 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203664 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - EACH ADDL 15 MINUTES 15 MINUTES 00750 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203672 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - EACH ADDL 15 MINUTES 15 MINUTES 00752 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203680 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - EACH ADDL 15 MINUTES 15 MINUTES 00754 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203797 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - EACH ADDL 15 MINUTES 15 MINUTES 00830 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203805 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REPAIR OF HERNIA - EACH ADDL 15 MINUTES 15 MINUTES 00832 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204340 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REVISE HIP REPAIR - 1ST 15 MINUTES 15 MINUTES 01215 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204340 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN REVISE HIP REPAIR - EACH ADDL 15 MINUTES 15 MINUTES 01215 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203003 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SALIVARY GLAND - 1ST 15 MINUTES 15 MINUTES 00100 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203003 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SALIVARY GLAND - EACH ADDL 15 MINUTES 15 MINUTES 00100 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204787 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER CASTING - 1ST 15 MINUTES 15 MINUTES 01680 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204787 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER CASTING - EACH ADDL 15 MINUTES 15 MINUTES 01680 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204720 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER JT AMPUT - 1ST 15 MINUTES 15 MINUTES 01634 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204720 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER JT AMPUT - EACH ADDL 15 MINUTES 15 MINUTES 01634 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204696 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER PROCEDURE - 1ST 15 MINUTES 15 MINUTES 01620 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204696 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER PROCEDURE - EACH ADDL 15 MINUTES 15 MINUTES 01620 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204746 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER REPLACEMT - 1ST 15 MINUTES 15 MINUTES 01638 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204746 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER REPLACEMT - EACH ADDL 15 MINUTES 15 MINUTES 01638 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204779 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER VEIN SURG - 1ST 15 MINUTES 15 MINUTES 01670 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204779 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER VEIN SURG - EACH ADDL 15 MINUTES 15 MINUTES 01670 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204753 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER VESSEL - 1ST 15 MINUTES 15 MINUTES 01654 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204753 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SHOULDER VESSEL - EACH ADDL 15 MINUTES 15 MINUTES 01654 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203557 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SITTING PROCEDURE - 1ST 15 MINUTES 15 MINUTES 00604 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203557 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SITTING PROCEDURE - EACH ADDL 15 MINUTES 15 MINUTES 00604 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203169 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SKULL DRAINAGE - 1ST 15 MINUTES 15 MINUTES 00212 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203169 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SKULL DRAINAGE - EACH ADDL 15 MINUTES 15 MINUTES 00212 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203177 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SKULL REPAIR/FRACT - 1ST 15 MINUTES 15 MINUTES 00215 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203177 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SKULL REPAIR/FRACT - EACH ADDL 15 MINUTES 15 MINUTES 00215 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203193 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPECIAL HEAD - 1ST 15 MINUTES 15 MINUTES 00218 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203193 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPECIAL HEAD - EACH ADDL 15 MINUTES 15 MINUTES 00218 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204076 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPERM DUCT SURGERY - 1ST 15 MINUTES 15 MINUTES 00922 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204076 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPERM DUCT SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00922 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203540 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPINE CORD SURGERY - 1ST 15 MINUTES 15 MINUTES 00600 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203565 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPINE CORD SURGERY - 1ST 15 MINUTES 15 MINUTES 00620 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203623 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPINE CORD SURGERY - 1ST 15 MINUTES 15 MINUTES 00670 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203540 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPINE CORD SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00600 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203565 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPINE CORD SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00620 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203623 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPINE CORD SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00670 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203615 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPINE MANIPULATION - 1ST 15 MINUTES 15 MINUTES 00640 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203615 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SPINE MANIPULATION - EACH ADDL 15 MINUTES 15 MINUTES 00640 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203474 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN STERNAL DEBRIDE - 1ST 15 MINUTES 15 MINUTES 00550 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203474 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN STERNAL DEBRIDE - EACH ADDL 15 MINUTES 15 MINUTES 00550 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204043 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN STONE REMOVAL - 1ST 15 MINUTES 15 MINUTES 00918 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204043 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN STONE REMOVAL - EACH ADDL 15 MINUTES 15 MINUTES 00918 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203748 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURG FOR OBESITY - 1ST 15 MINUTES 15 MINUTES 00797 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203748 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURG FOR OBESITY - EACH ADDL 15 MINUTES 15 MINUTES 00797 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203839 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURG LOWER ABDOMEN - 1ST 15 MINUTES 15 MINUTES 00840 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203839 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURG LOWER ABDOMEN - EACH ADDL 15 MINUTES 15 MINUTES 00840 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203706 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURG UPPER ABDOMEN - 1ST 15 MINUTES 15 MINUTES 00790 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203706 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURG UPPER ABDOMEN - EACH ADDL 15 MINUTES 15 MINUTES 00790 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204167 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURG VAG/URETHRAL - 1ST 15 MINUTES 15 MINUTES 00942 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204167 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURG VAG/URETHRAL - EACH ADDL 15 MINUTES 15 MINUTES 00942 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203268 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY OF BREAST - 1ST 15 MINUTES 15 MINUTES 00402 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203276 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY OF BREAST - 1ST 15 MINUTES 15 MINUTES 00404 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203284 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY OF BREAST - 1ST 15 MINUTES 15 MINUTES 00406 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203268 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY OF BREAST - EACH ADDL 15 MINUTES 15 MINUTES 00402 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203276 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY OF BREAST - EACH ADDL 15 MINUTES 15 MINUTES 00404 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203284 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY OF BREAST - EACH ADDL 15 MINUTES 15 MINUTES 00406 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204365 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY OF FEMUR - 1ST 15 MINUTES 15 MINUTES 01230 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204365 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY OF FEMUR - EACH ADDL 15 MINUTES 15 MINUTES 01230 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203300 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY SHOULDER - 1ST 15 MINUTES 15 MINUTES 00450 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204688 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY SHOULDER - 1ST 15 MINUTES 15 MINUTES 01610 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204712 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY SHOULDER - 1ST 15 MINUTES 15 MINUTES 01630 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203300 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY SHOULDER - EACH ADDL 15 MINUTES 15 MINUTES 00450 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204688 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY SHOULDER - EACH ADDL 15 MINUTES 15 MINUTES 01610 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204712 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN SURGERY SHOULDER - EACH ADDL 15 MINUTES 15 MINUTES 01630 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204084 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TESTIS EXPLORATION - 1ST 15 MINUTES 15 MINUTES 00924 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204084 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TESTIS EXPLORATION - EACH ADDL 15 MINUTES 15 MINUTES 00924 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204118 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TESTIS SUSPENSION - 1ST 15 MINUTES 15 MINUTES 00930 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204118 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TESTIS SUSPENSION - EACH ADDL 15 MINUTES 15 MINUTES 00930 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204407 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN THIGH ARTERIES SUR - 1ST 15 MINUTES 15 MINUTES 01270 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204407 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN THIGH ARTERIES SUR - EACH ADDL 15 MINUTES 15 MINUTES 01270 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203425 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TRACH-BRONCH RECON - 1ST 15 MINUTES 15 MINUTES 00539 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203425 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TRACH-BRONCH RECON - EACH ADDL 15 MINUTES 15 MINUTES 00539 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203466 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TRACHEA BRONCHI - 1ST 15 MINUTES 15 MINUTES 00548 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203466 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TRACHEA BRONCHI - EACH ADDL 15 MINUTES 15 MINUTES 00548 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203029 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TYMPANOTOMY - 1ST 15 MINUTES 15 MINUTES 00126 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203029 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN TYMPANOTOMY - EACH ADDL 15 MINUTES 15 MINUTES 00126 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204852 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPER ARM SURGERY - 1ST 15 MINUTES 15 MINUTES 01740 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204852 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPER ARM SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01740 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204910 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPER ARM VEIN SUR - 1ST 15 MINUTES 15 MINUTES 01780 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204910 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPER ARM VEIN SUR - EACH ADDL 15 MINUTES 15 MINUTES 01780 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204399 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPER LEG VEINS - 1ST 15 MINUTES 15 MINUTES 01260 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204399 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPER LEG VEINS - EACH ADDL 15 MINUTES 15 MINUTES 01260 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204894 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM ARTERY - 1ST 15 MINUTES 15 MINUTES 01770 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204894 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM ARTERY - EACH ADDL 15 MINUTES 15 MINUTES 01770 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204902 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM EMBOLECT - 1ST 15 MINUTES 15 MINUTES 01772 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204902 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM EMBOLECT - EACH ADDL 15 MINUTES 15 MINUTES 01772 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204837 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM PROCEDURE - 1ST 15 MINUTES 15 MINUTES 01730 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204837 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM PROCEDURE - EACH ADDL 15 MINUTES 15 MINUTES 01730 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204811 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM TENDON - 1ST 15 MINUTES 15 MINUTES 01714 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204811 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM TENDON - EACH ADDL 15 MINUTES 15 MINUTES 01714 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204928 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM VEIN REP - 1ST 15 MINUTES 15 MINUTES 01782 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204928 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN UPPR ARM VEIN REP - EACH ADDL 15 MINUTES 15 MINUTES 01782 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204175 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VAG HYSTERECTOMY - 1ST 15 MINUTES 15 MINUTES 00944 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204175 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VAG HYSTERECTOMY - EACH ADDL 15 MINUTES 15 MINUTES 00944 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205206 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VAGINAL DELIVERY - 1ST 15 MINUTES 15 MINUTES 01960 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205206 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VAGINAL DELIVERY - EACH ADDL 15 MINUTES 15 MINUTES 01960 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204191 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VAGINAL ENDOSCOPY - 1ST 15 MINUTES 15 MINUTES 00950 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204191 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VAGINAL ENDOSCOPY - EACH ADDL 15 MINUTES 15 MINUTES 00950 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204159 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VAGINAL PROCEDURES - 1ST 15 MINUTES 15 MINUTES 00940 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204159 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VAGINAL PROCEDURES - EACH ADDL 15 MINUTES 15 MINUTES 00940 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205008 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VASCULAR SHUNT SUR - 1ST 15 MINUTES 15 MINUTES 01844 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205008 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VASCULAR SHUNT SUR - EACH ADDL 15 MINUTES 15 MINUTES 01844 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204068 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VASECTOMY - 1ST 15 MINUTES 15 MINUTES 00921 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204068 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VASECTOMY - EACH ADDL 15 MINUTES 15 MINUTES 00921 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203052 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VITREORETINAL SURG - 1ST 15 MINUTES 15 MINUTES 00145 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203052 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN VITREORETINAL SURG - EACH ADDL 15 MINUTES 15 MINUTES 00145 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204977 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN WRIST REPLACEMENT - 1ST 15 MINUTES 15 MINUTES 01832 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98204977 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN WRIST REPLACEMENT - EACH ADDL 15 MINUTES 15 MINUTES 01832 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205255 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN/ANALG VAG DELIVERY - 1ST 15 MINUTES 15 MINUTES 01967 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205255 PHYSICIAN FEE - ANESTHESIA PF-ANES MIN/ANALG VAG DELIVERY - EACH ADDL 15 MINUTES 15 MINUTES 01967 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203441 PHYSICIAN FEE - ANESTHESIA PF-ANES MINESIA REMOVAL PLEURA - 1ST 15 MINUTES 15 MINUTES 00542 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203441 PHYSICIAN FEE - ANESTHESIA PF-ANES MINESIA REMOVAL PLEURA - EACH ADDL 15 MINUTES 15 MINUTES 00542 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205859 PHYSICIAN FEE - ANESTHESIA PF-ANES NEUROMD/NTRVRT CRV/TH 15 MINUTES 01941 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205867 PHYSICIAN FEE - ANESTHESIA PF-ANES NEUROMD/NTRVRT LMBR/SC 15 MINUTES 01942 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205826 PHYSICIAN FEE - ANESTHESIA PF-ANES NULYT AGT CRV/THRC 15 MINUTES 01939 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205834 PHYSICIAN FEE - ANESTHESIA PF-ANES NULYT AGT LMBR/SAC 15 MINUTES 01940 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203581 PHYSICIAN FEE - ANESTHESIA PF-ANES SPINE TRANSTHOR W/VENT - 1ST 15 MINUTES 15 MINUTES 00626 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203581 PHYSICIAN FEE - ANESTHESIA PF-ANES SPINE TRANSTHOR W/VENT - EACH ADDL 15 MINUTES 15 MINUTES 00626 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203573 PHYSICIAN FEE - ANESTHESIA PF-ANES SPINE TRANTHOR WO VENT - 1ST 15 MINUTES 15 MINUTES 00625 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98203573 PHYSICIAN FEE - ANESTHESIA PF-ANES SPINE TRANTHOR WO VENT - EACH ADDL 15 MINUTES 15 MINUTES 00625 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205073 PHYSICIAN FEE - ANESTHESIA PF-ANES THER INTERV RAD ARTRL - 1ST 15 MINUTES 15 MINUTES 01924 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205073 PHYSICIAN FEE - ANESTHESIA PF-ANES THER INTERV RAD ARTRL - EACH ADDL 15 MINUTES 15 MINUTES 01924 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205081 PHYSICIAN FEE - ANESTHESIA PF-ANES THER INTERVEN RAD CARD - 1ST 15 MINUTES 15 MINUTES 01925 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205081 PHYSICIAN FEE - ANESTHESIA PF-ANES THER INTERVEN RAD CARD - EACH ADDL 15 MINUTES 15 MINUTES 01925 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205115 PHYSICIAN FEE - ANESTHESIA PF-ANES THER INTERVEN RAD TIPS - 1ST 15 MINUTES 15 MINUTES 01931 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205115 PHYSICIAN FEE - ANESTHESIA PF-ANES THER INTERVEN RAD TIPS - EACH ADDL 15 MINUTES 15 MINUTES 01931 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205107 PHYSICIAN FEE - ANESTHESIA PF-ANES THER INTERVEN RAD VEIN - 1ST 15 MINUTES 15 MINUTES 01930 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205107 PHYSICIAN FEE - ANESTHESIA PF-ANES THER INTERVEN RAD VEIN - EACH ADDL 15 MINUTES 15 MINUTES 01930 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205131 PHYSICIAN FEE - ANESTHESIA PF-ANES TX INTERV RAD CRAN VN - 1ST 15 MINUTES 15 MINUTES 01933 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205131 PHYSICIAN FEE - ANESTHESIA PF-ANES TX INTERV RAD CRAN VN - EACH ADDL 15 MINUTES 15 MINUTES 01933 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205099 PHYSICIAN FEE - ANESTHESIA PF-ANES TX INTERV RAD HRT/CRAN - 1ST 15 MINUTES 15 MINUTES 01926 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205099 PHYSICIAN FEE - ANESTHESIA PF-ANES TX INTERV RAD HRT/CRAN - EACH ADDL 15 MINUTES 15 MINUTES 01926 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205123 PHYSICIAN FEE - ANESTHESIA PF-ANES TX INTERV RAD TH VEIN - 1ST 15 MINUTES 15 MINUTES 01932 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205123 PHYSICIAN FEE - ANESTHESIA PF-ANES TX INTERV RAD TH VEIN - EACH ADDL 15 MINUTES 15 MINUTES 01932 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205719 PHYSICIAN FEE - ANESTHESIA PF-ANES UPR GI NDSC PX ERCP - 1ST 15 MINUTES 15 MINUTES 00732 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205719 PHYSICIAN FEE - ANESTHESIA PF-ANES UPR GI NDSC PX ERCP - EACH ADDL 15 MINUTES 15 MINUTES 00732 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205693 PHYSICIAN FEE - ANESTHESIA PF-ANES UPR GI NDSC PX NOS - 1ST 15 MINUTES 15 MINUTES 00731 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205693 PHYSICIAN FEE - ANESTHESIA PF-ANES UPR GI NDSC PX NOS - EACH ADDL 15 MINUTES 15 MINUTES 00731 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205743 PHYSICIAN FEE - ANESTHESIA PF-ANES UPR LWR GI NDSC PX - 1ST 15 MINUTES 15 MINUTES 00813 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205743 PHYSICIAN FEE - ANESTHESIA PF-ANES UPR LWR GI NDSC PX - EACH ADDL 15 MINUTES 15 MINUTES 00813 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202872 PHYSICIAN FEE - ANESTHESIA PF-ANES W/EMERGENCY CONDITIONS EACH 99140 $500.00 960 $350.00 $250.00 $400.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205297 PHYSICIAN FEE - ANESTHESIA PF-ANES/ANALG CS DELIVER ADDON - 1ST 15 MINUTES 15 MINUTES 01968 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205297 PHYSICIAN FEE - ANESTHESIA PF-ANES/ANALG CS DELIVER ADDON - EACH ADDL 15 MINUTES 15 MINUTES 01968 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202849 PHYSICIAN FEE - ANESTHESIA PF-ANESTH - PT AGE <1 OR 70+ EACH 99100 $500.00 960 $350.00 $250.00 $400.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205404 PHYSICIAN FEE - ANESTHESIA PF-ANESTH AMPUTATION OF PENIS - 1ST 15 MINUTES 15 MINUTES 00932 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205404 PHYSICIAN FEE - ANESTHESIA PF-ANESTH AMPUTATION OF PENIS - EACH ADDL 15 MINUTES 15 MINUTES 00932 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205339 PHYSICIAN FEE - ANESTHESIA PF-ANESTH ANKLE/FT ARTHROSCOPY - 1ST 15 MINUTES 15 MINUTES 01464 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205339 PHYSICIAN FEE - ANESTHESIA PF-ANESTH ANKLE/FT ARTHROSCOPY - EACH ADDL 15 MINUTES 15 MINUTES 01464 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205438 PHYSICIAN FEE - ANESTHESIA PF-ANESTH BLEPHAROPLASTY - 1ST 15 MINUTES 15 MINUTES 00103 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205438 PHYSICIAN FEE - ANESTHESIA PF-ANESTH BLEPHAROPLASTY - EACH ADDL 15 MINUTES 15 MINUTES 00103 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205685 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CABG W/PUMP - 1ST 15 MINUTES 15 MINUTES 00567 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205685 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CABG W/PUMP - EACH ADDL 15 MINUTES 15 MINUTES 00567 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205370 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CHEST LINING BIOPSY - 1ST 15 MINUTES 15 MINUTES 00522 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205370 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CHEST LINING BIOPSY - EACH ADDL 15 MINUTES 15 MINUTES 00522 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205669 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CHEST SURGERY - 1ST 15 MINUTES 15 MINUTES 00540 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205669 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CHEST SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00540 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205511 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CLEFT PALATE REPAIR - 1ST 15 MINUTES 15 MINUTES 00172 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205511 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CLEFT PALATE REPAIR - EACH ADDL 15 MINUTES 15 MINUTES 00172 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205503 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CORNEAL TRANSPLANT - 1ST 15 MINUTES 15 MINUTES 00144 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205503 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CORNEAL TRANSPLANT - EACH ADDL 15 MINUTES 15 MINUTES 00144 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205636 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CS HYSTERECTOMY - 1ST 15 MINUTES 15 MINUTES 01963 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205636 PHYSICIAN FEE - ANESTHESIA PF-ANESTH CS HYSTERECTOMY - EACH ADDL 15 MINUTES 15 MINUTES 01963 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205354 PHYSICIAN FEE - ANESTHESIA PF-ANESTH EAR EXAM - 1ST 15 MINUTES 15 MINUTES 00124 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205354 PHYSICIAN FEE - ANESTHESIA PF-ANESTH EAR EXAM - EACH ADDL 15 MINUTES 15 MINUTES 00124 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205446 PHYSICIAN FEE - ANESTHESIA PF-ANESTH EAR SURGERY - 1ST 15 MINUTES 15 MINUTES 00120 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205446 PHYSICIAN FEE - ANESTHESIA PF-ANESTH EAR SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00120 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205396 PHYSICIAN FEE - ANESTHESIA PF-ANESTH FOR LIVER BIOPSY - 1ST 15 MINUTES 15 MINUTES 00702 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205396 PHYSICIAN FEE - ANESTHESIA PF-ANESTH FOR LIVER BIOPSY - EACH ADDL 15 MINUTES 15 MINUTES 00702 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205487 PHYSICIAN FEE - ANESTHESIA PF-ANESTH HUMERUS SURGERY - 1ST 15 MINUTES 15 MINUTES 01742 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205487 PHYSICIAN FEE - ANESTHESIA PF-ANESTH HUMERUS SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01742 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205362 PHYSICIAN FEE - ANESTHESIA PF-ANESTH IRIDECTOMY - 1ST 15 MINUTES 15 MINUTES 00147 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205362 PHYSICIAN FEE - ANESTHESIA PF-ANESTH IRIDECTOMY - EACH ADDL 15 MINUTES 15 MINUTES 00147 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205461 PHYSICIAN FEE - ANESTHESIA PF-ANESTH KNEE AREA SURGERY - 1ST 15 MINUTES 15 MINUTES 01360 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205461 PHYSICIAN FEE - ANESTHESIA PF-ANESTH KNEE AREA SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01360 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205628 PHYSICIAN FEE - ANESTHESIA PF-ANESTH KNEE ARTERY SURG - 1ST 15 MINUTES 15 MINUTES 01442 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205628 PHYSICIAN FEE - ANESTHESIA PF-ANESTH KNEE ARTERY SURG - EACH ADDL 15 MINUTES 15 MINUTES 01442 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205321 PHYSICIAN FEE - ANESTHESIA PF-ANESTH KNEE VEINS SURGERY - 1ST 15 MINUTES 15 MINUTES 01430 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205321 PHYSICIAN FEE - ANESTHESIA PF-ANESTH KNEE VEINS SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01430 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205347 PHYSICIAN FEE - ANESTHESIA PF-ANESTH LOWER LEG CASTING - 1ST 15 MINUTES 15 MINUTES 01490 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205347 PHYSICIAN FEE - ANESTHESIA PF-ANESTH LOWER LEG CASTING - EACH ADDL 15 MINUTES 15 MINUTES 01490 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205529 PHYSICIAN FEE - ANESTHESIA PF-ANESTH NECK ORGAN 1YR/> - 1ST 15 MINUTES 15 MINUTES 00320 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205529 PHYSICIAN FEE - ANESTHESIA PF-ANESTH NECK ORGAN 1YR/> - EACH ADDL 15 MINUTES 15 MINUTES 00320 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205453 PHYSICIAN FEE - ANESTHESIA PF-ANESTH NECK VESSEL SURGERY - 1ST 15 MINUTES 15 MINUTES 00352 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205453 PHYSICIAN FEE - ANESTHESIA PF-ANESTH NECK VESSEL SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00352 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205578 PHYSICIAN FEE - ANESTHESIA PF-ANESTH NOSE/SINUS SURGERY - 1ST 15 MINUTES 15 MINUTES 00162 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205578 PHYSICIAN FEE - ANESTHESIA PF-ANESTH NOSE/SINUS SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00162 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205594 PHYSICIAN FEE - ANESTHESIA PF-ANESTH PERINEAL SURGERY - 1ST 15 MINUTES 15 MINUTES 00904 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205594 PHYSICIAN FEE - ANESTHESIA PF-ANESTH PERINEAL SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00904 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205560 PHYSICIAN FEE - ANESTHESIA PF-ANESTH RADICAL HUMERUS SURG - 1ST 15 MINUTES 15 MINUTES 01756 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205560 PHYSICIAN FEE - ANESTHESIA PF-ANESTH RADICAL HUMERUS SURG - EACH ADDL 15 MINUTES 15 MINUTES 01756 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205610 PHYSICIAN FEE - ANESTHESIA PF-ANESTH REMOVAL OF BLADDER - 1ST 15 MINUTES 15 MINUTES 00864 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205610 PHYSICIAN FEE - ANESTHESIA PF-ANESTH REMOVAL OF BLADDER - EACH ADDL 15 MINUTES 15 MINUTES 00864 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205495 PHYSICIAN FEE - ANESTHESIA PF-ANESTH REPAIR OF CLEFT LIP - 1ST 15 MINUTES 15 MINUTES 00102 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205495 PHYSICIAN FEE - ANESTHESIA PF-ANESTH REPAIR OF CLEFT LIP - EACH ADDL 15 MINUTES 15 MINUTES 00102 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205586 PHYSICIAN FEE - ANESTHESIA PF-ANESTH REPAIR OF HERNIA - 1ST 15 MINUTES 15 MINUTES 00756 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205586 PHYSICIAN FEE - ANESTHESIA PF-ANESTH REPAIR OF HERNIA - EACH ADDL 15 MINUTES 15 MINUTES 00756 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205552 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SHOULDER ARTERY SURG - 1ST 15 MINUTES 15 MINUTES 01650 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205552 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SHOULDER ARTERY SURG - EACH ADDL 15 MINUTES 15 MINUTES 01650 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205651 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SHOULDER VESSEL SURG - 1ST 15 MINUTES 15 MINUTES 01652 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205651 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SHOULDER VESSEL SURG - EACH ADDL 15 MINUTES 15 MINUTES 01652 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205305 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SKIN EXT/PER/ATRUNK - 1ST 15 MINUTES 15 MINUTES 00400 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205305 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SKIN EXT/PER/ATRUNK - EACH ADDL 15 MINUTES 15 MINUTES 00400 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205644 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SKULL DRAINAGE - 1ST 15 MINUTES 15 MINUTES 00214 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205644 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SKULL DRAINAGE - EACH ADDL 15 MINUTES 15 MINUTES 00214 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205602 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SPINE CORD SURGERY - 1ST 15 MINUTES 15 MINUTES 00630 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205602 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SPINE CORD SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 00630 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205545 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SURGERY OF ABDOMEN - 1ST 15 MINUTES 15 MINUTES 00860 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205545 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SURGERY OF ABDOMEN - EACH ADDL 15 MINUTES 15 MINUTES 00860 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205677 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SURGERY OF RIB - 1ST 15 MINUTES 15 MINUTES 00474 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205677 PHYSICIAN FEE - ANESTHESIA PF-ANESTH SURGERY OF RIB - EACH ADDL 15 MINUTES 15 MINUTES 00474 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205537 PHYSICIAN FEE - ANESTHESIA PF-ANESTH TUBAL LIGATION - 1ST 15 MINUTES 15 MINUTES 00851 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205537 PHYSICIAN FEE - ANESTHESIA PF-ANESTH TUBAL LIGATION - EACH ADDL 15 MINUTES 15 MINUTES 00851 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205420 PHYSICIAN FEE - ANESTHESIA PF-ANESTH UPPER LEG SURGERY - 1ST 15 MINUTES 15 MINUTES 01250 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205420 PHYSICIAN FEE - ANESTHESIA PF-ANESTH UPPER LEG SURGERY - EACH ADDL 15 MINUTES 15 MINUTES 01250 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205479 PHYSICIAN FEE - ANESTHESIA PF-ANESTH UPPR ARM TENDON SURG - 1ST 15 MINUTES 15 MINUTES 01712 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205479 PHYSICIAN FEE - ANESTHESIA PF-ANESTH UPPR ARM TENDON SURG - EACH ADDL 15 MINUTES 15 MINUTES 01712 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205388 PHYSICIAN FEE - ANESTHESIA PF-ANESTH VASCULAR ACCESS - 1ST 15 MINUTES 15 MINUTES 00532 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205388 PHYSICIAN FEE - ANESTHESIA PF-ANESTH VASCULAR ACCESS - EACH ADDL 15 MINUTES 15 MINUTES 00532 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202864 PHYSICIAN FEE - ANESTHESIA PF-ANESTHESIA W/HYPOTENSION EACH 99135 $500.00 960 $350.00 $250.00 $400.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202856 PHYSICIAN FEE - ANESTHESIA PF-ANESTHESIA W/HYPOTHERMIA EACH 99116 $500.00 960 $350.00 $250.00 $400.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202963 PHYSICIAN FEE - ANESTHESIA PF-MOD SED ENDO SERVICE >5YRS EACH G0500 $17.00 960 $11.90 $8.50 $13.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202930 PHYSICIAN FEE - ANESTHESIA PF-MOD SED OTH DR/QHP <5 YRS EACH 99155 $220.00 960 $154.00 $110.00 $176.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202948 PHYSICIAN FEE - ANESTHESIA PF-MOD SED OTH DR/QHP 5/>YRS EACH 99156 $198.00 960 $138.60 $99.00 $158.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202955 PHYSICIAN FEE - ANESTHESIA PF-MOD SED OTHER DR/QHP EA EACH 99157 $155.00 960 $108.50 $77.50 $124.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202914 PHYSICIAN FEE - ANESTHESIA PF-MOD SED SAME DR/QHP <5 YRS EACH 99151 $62.00 960 $43.40 $31.00 $49.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202922 PHYSICIAN FEE - ANESTHESIA PF-MOD SED SAME DR/QHP EA EACH 99153 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202906 PHYSICIAN FEE - ANESTHESIA PF-MOD SED SAME PHYS/QHP 5+YRS EACH 99152 $33.00 960 $23.10 $16.50 $26.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205263 PHYSICIAN FEE - ANESTHESIA PF-SUPPORT FOR ORGAN DONOR - 1ST 15 MINUTES 15 MINUTES 01990 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98205263 PHYSICIAN FEE - ANESTHESIA PF-SUPPORT FOR ORGAN DONOR - EACH ADDL 15 MINUTES 15 MINUTES 01990 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98202880 PHYSICIAN FEE - ANESTHESIA PF-UNLISTED ANESTH PROCEDURE EACH 01999 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300172 PHYSICIAN FEE - AUDIOLOGY PF-AUD ACOUSTIC REFLEX TESTING EACH 92568 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300404 PHYSICIAN FEE - AUDIOLOGY PF-AUD ASSESSMENT REHAB 1ST HR EACH 92626 $186.00 960 $130.20 $93.00 $148.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300388 PHYSICIAN FEE - AUDIOLOGY PF-AUD ASSESSMENT TINNITUS EACH 92625 $153.00 960 $107.10 $76.50 $122.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300412 PHYSICIAN FEE - AUDIOLOGY PF-AUD ASSESSMNT REHAB ADD 15M EACH 92627 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300420 PHYSICIAN FEE - AUDIOLOGY PF-AUD BRAINSTEM IMPLT PROGRAM EACH 92640 $233.00 960 $163.10 $116.50 $186.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300347 PHYSICIAN FEE - AUDIOLOGY PF-AUD COCHL IMP <7 YRS REPROG EACH 92602 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300354 PHYSICIAN FEE - AUDIOLOGY PF-AUD COCHL IMP 7 OR > YRS PR EACH 92603 $297.00 960 $207.90 $148.50 $237.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300339 PHYSICIAN FEE - AUDIOLOGY PF-AUD COCHLEAR IMP <7 YRS FU EACH 92601 $306.00 960 $214.20 $153.00 $244.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300099 PHYSICIAN FEE - AUDIOLOGY PF-AUD COMP EVAL THRESH/RECOG EACH 92557 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300271 PHYSICIAN FEE - AUDIOLOGY PF-AUD CONDITION PLAY AUDIOM EACH 92582 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300313 PHYSICIAN FEE - AUDIOLOGY PF-AUD EAR PROTECTOR MEASURES EACH 92596 $195.00 960 $136.50 $97.50 $156.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300370 PHYSICIAN FEE - AUDIOLOGY PF-AUD EVAL CENTRL FUNC ADD 15 EACH 92621 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300552 PHYSICIAN FEE - AUDIOLOGY PF-AUD EVOKED OTOAC EMISS COMP EACH 92588 $14.00 960 $9.80 $7.00 $11.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300545 PHYSICIAN FEE - AUDIOLOGY PF-AUD EVOKED OTOAC EMISS LTD EACH 92587 $11.00 960 $7.70 $5.50 $8.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300529 PHYSICIAN FEE - AUDIOLOGY PF-AUD EVOKED POTENTIAL COMP EACH 92651 $211.00 960 $147.70 $105.50 $168.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300305 PHYSICIAN FEE - AUDIOLOGY PF-AUD EVOKED POTENTIAL LTD EACH 92652 $286.00 960 $200.20 $143.00 $228.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300206 PHYSICIAN FEE - AUDIOLOGY PF-AUD FILTERED SPEECH TEST EACH 92571 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300198 PHYSICIAN FEE - AUDIOLOGY PF-AUD IMMITTANCE TESTING EACH 92570 $73.00 960 $51.10 $36.50 $58.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300123 PHYSICIAN FEE - AUDIOLOGY PF-AUD LOUDNESS BALANCE TEST EACH 92562 $123.00 960 $86.10 $61.50 $98.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300016 PHYSICIAN FEE - AUDIOLOGY PF-AUD NASAL FUNCTION STUDY EACH 92512 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300487 PHYSICIAN FEE - AUDIOLOGY PF-AUD OPTOKINETC NYSTAG W/REC EACH 92544 $11.00 960 $7.70 $5.50 $8.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300495 PHYSICIAN FEE - AUDIOLOGY PF-AUD OSCILLATING TRACK W/REC EACH 92545 $11.00 960 $7.70 $5.50 $8.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300453 PHYSICIAN FEE - AUDIOLOGY PF-AUD POSITIONAL NYSTAG W/REC EACH 92542 $12.00 960 $8.40 $6.00 $9.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300511 PHYSICIAN FEE - AUDIOLOGY PF-AUD POSTUROGRAPHY COMPUTE EACH 92548 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300065 PHYSICIAN FEE - AUDIOLOGY PF-AUD PURE TONE AIR & BONE EACH 92553 $117.00 960 $81.90 $58.50 $93.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300057 PHYSICIAN FEE - AUDIOLOGY PF-AUD PURE TONE AIR ONLY EACH 92552 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300289 PHYSICIAN FEE - AUDIOLOGY PF-AUD SELECT PICTURE AUDIOMET EACH 92583 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300222 PHYSICIAN FEE - AUDIOLOGY PF-AUD SENSORINEURL ACUITY LVL EACH 92575 $188.00 960 $131.60 $94.00 $150.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300503 PHYSICIAN FEE - AUDIOLOGY PF-AUD SINUSOIDAL ROTATE W/REC EACH 92546 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300073 PHYSICIAN FEE - AUDIOLOGY PF-AUD SPEECH THRESHOLD EACH 92555 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300081 PHYSICIAN FEE - AUDIOLOGY PF-AUD SPEECH THRESHOLD W/REC EACH 92556 $114.00 960 $79.80 $57.00 $91.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300438 PHYSICIAN FEE - AUDIOLOGY PF-AUD SPONTANEOUS NYSTG W/REC EACH 92540 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300446 PHYSICIAN FEE - AUDIOLOGY PF-AUD SPONTANEOUS NYSTG W/REC EACH 92541 $12.00 960 $8.40 $6.00 $9.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300214 PHYSICIAN FEE - AUDIOLOGY PF-AUD STAGGERED SPONDAIC WORD EACH 92572 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300156 PHYSICIAN FEE - AUDIOLOGY PF-AUD STENGER TEST PURE TONE EACH 92565 $54.00 960 $37.80 $27.00 $43.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300248 PHYSICIAN FEE - AUDIOLOGY PF-AUD STENGER TEST SPEECH EACH 92577 $57.00 960 $39.90 $28.50 $45.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300230 PHYSICIAN FEE - AUDIOLOGY PF-AUD SYNTH SENTENCE ID TEST EACH 92576 $108.00 960 $75.60 $54.00 $86.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300131 PHYSICIAN FEE - AUDIOLOGY PF-AUD TONE DECAY TEST EACH 92563 $88.00 960 $61.60 $44.00 $70.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300164 PHYSICIAN FEE - AUDIOLOGY PF-AUD TYMPANOMETRY IMPED TEST EACH 92567 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300024 PHYSICIAN FEE - AUDIOLOGY PF-AUD VERTICAL ELECTRODE USE EACH 92547 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300263 PHYSICIAN FEE - AUDIOLOGY PF-AUD VISUAL REINFORCE AUDIO EACH 92579 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300297 PHYSICIAN FEE - AUDIOLOGY PF-ELECTROCOCHLEOGRAPHY EACH 92584 $280.00 960 $196.00 $140.00 $224.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300008 PHYSICIAN FEE - AUDIOLOGY PF-NASOPHARYNGOSCOPY EACH 92511 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300362 PHYSICIAN FEE - AUDIOLOGY PF-REPROG COCHLEAR IMPLT 7/> EACH 92604 $165.00 960 $115.50 $82.50 $132.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97300032 PHYSICIAN FEE - AUDIOLOGY PF-TYMPANOMETRY&REFLEX THRESH EACH 92550 $55.00 960 $38.50 $27.50 $44.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500516 PHYSICIAN FEE - CARDIAC CATH PF-ABLATE ARRHYTHMIA ADD ON EACH 93655 $845.00 960 $591.50 $422.50 $676.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500482 PHYSICIAN FEE - CARDIAC CATH PF-ABLATE HEART DYSRYTHM FOCUS EACH 93650 "$1,600.00 " 960 "$1,120.00 " $800.00 "$1,280.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500698 PHYSICIAN FEE - CARDIAC CATH PF-ANLYS PACING DUAL W/O PRGM EACH 93283 $108.00 960 $75.60 $54.00 $86.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500235 PHYSICIAN FEE - CARDIAC CATH PF-BALLN VALVULOPLASTY AO VLVE EACH 92986 "$3,655.00 " 960 "$2,558.50 " "$1,827.50 " "$2,924.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500250 PHYSICIAN FEE - CARDIAC CATH PF-BALLN VALVULOPLASTY MI VLVE EACH 92987 "$3,766.00 " 960 "$2,636.20 " "$1,883.00 " "$3,012.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500268 PHYSICIAN FEE - CARDIAC CATH PF-BALLN VALVULOPLASTY PU VLVE EACH 92990 "$3,014.00 " 960 "$2,109.80 " "$1,507.00 " "$2,411.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500557 PHYSICIAN FEE - CARDIAC CATH PF-BIOIMPEDANCE CV ANALYSIS EACH 93701 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500565 PHYSICIAN FEE - CARDIAC CATH PF-BIS XTRACELL FLUID ANALYSIS EACH 93702 $309.00 960 $216.30 $154.50 $247.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501043 PHYSICIAN FEE - CARDIAC CATH PF-BUNDLE OF HIS RECORDING EACH 93600 $257.00 960 $179.90 $128.50 $205.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500607 PHYSICIAN FEE - CARDIAC CATH PF-CARDIAC DRUG STRESS TEST EACH 93024 $137.00 960 $95.90 $68.50 $109.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500201 PHYSICIAN FEE - CARDIAC CATH PF-CARDIOASSIST EXTERNAL EACH 92971 $276.00 960 $193.20 $138.00 $220.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500193 PHYSICIAN FEE - CARDIAC CATH PF-CARDIOASSIST INTERNAL EACH 92970 $522.00 960 $365.40 $261.00 $417.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500185 PHYSICIAN FEE - CARDIAC CATH PF-CARDIOVERSION ELECTRIC INT EACH 92961 $673.00 960 $471.10 $336.50 $538.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500227 PHYSICIAN FEE - CARDIAC CATH PF-CATH PLACE CARDIO BRACHYTX EACH 92974 $447.00 960 $312.90 $223.50 $357.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500425 PHYSICIAN FEE - CARDIAC CATH PF-CLOSURE ASD PFO FENESTRTION EACH 93580 "$2,694.00 " 960 "$1,885.80 " "$1,347.00 " "$2,155.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500433 PHYSICIAN FEE - CARDIAC CATH PF-CLOSURE VSD EACH 93581 "$3,669.00 " 960 "$2,568.30 " "$1,834.50 " "$2,935.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500854 PHYSICIAN FEE - CARDIAC CATH PF-CORO ANGIO & BYPASS GRAFTS EACH 93455 $755.00 960 $528.50 $377.50 $604.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500847 PHYSICIAN FEE - CARDIAC CATH PF-CORONARY ANGIO EACH 93454 $647.00 960 $452.90 $323.50 $517.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500474 PHYSICIAN FEE - CARDIAC CATH PF-ELECTROPHYS MAP 3D ADD-ON EACH 93613 $806.00 960 $564.20 $403.00 $644.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501209 PHYSICIAN FEE - CARDIAC CATH PF-ELECTROPHYSIOLOGIC STUDY EACH 93624 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501142 PHYSICIAN FEE - CARDIAC CATH PF-ELECTROPHYSIOLOGY EVAL EACH 93619 "$1,004.00 " 960 $702.80 $502.00 $803.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501167 PHYSICIAN FEE - CARDIAC CATH PF-ELECTROPHYSIOLOGY EVAL EACH 93620 "$1,104.00 " 960 $772.80 $552.00 $883.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501175 PHYSICIAN FEE - CARDIAC CATH PF-ELECTROPHYSIOLOGY EVAL EACH 93621 $222.00 960 $155.40 $111.00 $177.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501183 PHYSICIAN FEE - CARDIAC CATH PF-ELECTROPHYSIOLOGY EVAL EACH 93622 $457.00 960 $319.90 $228.50 $365.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501241 PHYSICIAN FEE - CARDIAC CATH PF-ELECTROPHYSIOLOGY EVAL EACH 93641 $834.00 960 $583.80 $417.00 $667.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501258 PHYSICIAN FEE - CARDIAC CATH PF-ELECTROPHYSIOLOGY EVAL EACH 93642 $208.00 960 $145.60 $104.00 $166.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501266 PHYSICIAN FEE - CARDIAC CATH PF-ELECTROPHYSIOLOGY EVAL EACH 93644 $129.00 960 $90.30 $64.50 $103.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500508 PHYSICIAN FEE - CARDIAC CATH PF-EP & ABLATE VENTRIC TACHY EACH 93654 "$2,776.00 " 960 "$1,943.20 " "$1,388.00 " "$2,220.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500490 PHYSICIAN FEE - CARDIAC CATH PF-EP&ABLATE SUPRAVENT ARRHYT EACH 93653 "$2,304.00 " 960 "$1,612.80 " "$1,152.00 " "$1,843.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501118 PHYSICIAN FEE - CARDIAC CATH PF-ESOPHAGEAL REC W/O PACING EACH 93615 $42.00 960 $29.40 $21.00 $33.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501126 PHYSICIAN FEE - CARDIAC CATH PF-ESOPHAGEAL REC W/PACING EACH 93616 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501795 PHYSICIAN FEE - CARDIAC CATH PF-EVAL PHONE RHYTHM STRIP EACH 93293 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501233 PHYSICIAN FEE - CARDIAC CATH PF-EVALUATION HEART DEVICE EACH 93640 $476.00 960 $333.20 $238.00 $380.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100216 PHYSICIAN FEE - CARDIAC CATH PF-EXT ECG COMPLETE EACH 93241 $652.00 960 $456.40 $326.00 $521.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100190 PHYSICIAN FEE - CARDIAC CATH PF-EXT ECG RECORDING EACH 93242 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100182 PHYSICIAN FEE - CARDIAC CATH PF-EXT ECG REVIEW AND INTERP EACH 93241 $652.00 960 $456.40 $326.00 $521.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100208 PHYSICIAN FEE - CARDIAC CATH PF-EXT ECG SCAN W/REPORT EACH 93245 $686.00 960 $480.20 $343.00 $548.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501217 PHYSICIAN FEE - CARDIAC CATH PF-HEART PACING MAPPING EACH 93631 "$1,078.00 " 960 $754.60 $539.00 $862.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501134 PHYSICIAN FEE - CARDIAC CATH PF-HEART RHYTHM PACING EACH 93618 $516.00 960 $361.20 $258.00 $412.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500771 PHYSICIAN FEE - CARDIAC CATH PF-ICM DEVICE EVAL EACH 93290 $53.00 960 $37.10 $26.50 $42.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501308 PHYSICIAN FEE - CARDIAC CATH PF-ILIAC ART ANGIO CARD CATH EACH G0278 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500359 PHYSICIAN FEE - CARDIAC CATH PF-INJECT CONGENITAL CARD CATH EACH 93563 $139.00 960 $97.30 $69.50 $111.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500367 PHYSICIAN FEE - CARDIAC CATH PF-INJECT HRT CONGNTL ART/GRFT EACH 93564 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500375 PHYSICIAN FEE - CARDIAC CATH PF-INJECT L VENTR/ATRIAL ANGIO EACH 93565 $76.00 960 $53.20 $38.00 $60.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500391 PHYSICIAN FEE - CARDIAC CATH PF-INJECT R VENTR/ATRIAL ANGIO EACH 93566 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500342 PHYSICIAN FEE - CARDIAC CATH PF-INSERT/PLACE HEART CATHETER EACH 93503 $228.00 960 $159.60 $114.00 $182.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500789 PHYSICIAN FEE - CARDIAC CATH PF-INTEROG IMPLT LOOP RECORDER EACH 93291 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501779 PHYSICIAN FEE - CARDIAC CATH PF-INTERROG IMPLANT DEFIB DEV EACH 93289 $91.00 960 $63.70 $45.50 $72.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500755 PHYSICIAN FEE - CARDIAC CATH PF-INTERROG PACER 1-MUL LEAD EACH 93288 $51.00 960 $35.70 $25.50 $40.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500797 PHYSICIAN FEE - CARDIAC CATH PF-INTERROG WEARABLE DEFIB SYS EACH 93292 $53.00 960 $37.10 $26.50 $42.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500631 PHYSICIAN FEE - CARDIAC CATH PF-INTERROGATE SUBQ DEFIB EACH 93261 $88.00 960 $61.60 $44.00 $70.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501092 PHYSICIAN FEE - CARDIAC CATH PF-INTRA-ATRIAL PACING EACH 93610 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501050 PHYSICIAN FEE - CARDIAC CATH PF-INTRA-ATRIAL RECORDING EACH 93602 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501282 PHYSICIAN FEE - CARDIAC CATH PF-INTRACARDIAC ECG (ICE) EACH 93662 $174.00 960 $121.80 $87.00 $139.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501035 PHYSICIAN FEE - CARDIAC CATH PF-INTRAVASC DOPPLER FLOW ADDL EACH 93572 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501027 PHYSICIAN FEE - CARDIAC CATH PF-INTRAVASC DOPPLER FLOW INIT EACH 93571 $195.00 960 $136.50 $97.50 $156.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501100 PHYSICIAN FEE - CARDIAC CATH PF-INTRAVENTRICULAR PACING EACH 93612 $212.00 960 $148.40 $106.00 $169.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500821 PHYSICIAN FEE - CARDIAC CATH PF-LEFT HEART CATH WO CORO EACH 93452 $641.00 960 $448.70 $320.50 $512.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500896 PHYSICIAN FEE - CARDIAC CATH PF-LEFT HEART CATH&CORONARIES EACH 93458 $800.00 960 $560.00 $400.00 $640.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500904 PHYSICIAN FEE - CARDIAC CATH PF-LHC CORONARIES & BYPASS GR EACH 93459 $906.00 960 $634.20 $453.00 $724.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500326 PHYSICIAN FEE - CARDIAC CATH PF-LHC TRANSSEPT PUNCT-ADD ON EACH 93462 $572.00 960 $400.40 $286.00 $457.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500920 PHYSICIAN FEE - CARDIAC CATH PF-LHC&RHC CORONARIES & BYPASS EACH 93461 "$1,119.00 " 960 $783.30 $559.50 $895.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501076 PHYSICIAN FEE - CARDIAC CATH PF-MAP TACHYCARDIA ADD-ON EACH 93609 $356.00 960 $249.20 $178.00 $284.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500615 PHYSICIAN FEE - CARDIAC CATH PF-MICROVOLT T-WAVE ASSESS EACH 93025 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500086 PHYSICIAN FEE - CARDIAC CATH PF-PERC TL ATHERECTOMY EA ADDL EACH 92934 "$1,025.00 " 960 $717.50 $512.50 $820.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500078 PHYSICIAN FEE - CARDIAC CATH PF-PERC TL ATHERECTOMY SGL EACH 92933 "$1,826.00 " 960 "$1,278.20 " $913.00 "$1,460.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500029 PHYSICIAN FEE - CARDIAC CATH PF-PERC TL CORO ATHERECTMY SGL EACH 92924 "$1,746.00 " 960 "$1,222.20 " $873.00 "$1,396.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500045 PHYSICIAN FEE - CARDIAC CATH PF-PERC TL CORO ATHERECTMY-ADD EACH 92925 "$1,025.00 " 960 $717.50 $512.50 $820.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500144 PHYSICIAN FEE - CARDIAC CATH PF-PERC TL REVASCULARIZAT ADD EACH 92944 "$1,025.00 " 960 $717.50 $512.50 $820.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500136 PHYSICIAN FEE - CARDIAC CATH PF-PERC TL REVASCULARIZAT SGL EACH 92943 "$1,828.00 " 960 "$1,279.60 " $914.00 "$1,462.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500110 PHYSICIAN FEE - CARDIAC CATH PF-PERC TL VASCULARIZATION ADD EACH 92938 "$1,025.00 " 960 $717.50 $512.50 $820.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500748 PHYSICIAN FEE - CARDIAC CATH PF-PERI-PX DEVICE EVAL & PRGR EACH 93287 $53.00 960 $37.10 $26.50 $42.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500441 PHYSICIAN FEE - CARDIAC CATH PF-PERQ TRANSCATH CLOSURE PDA EACH 93582 "$1,833.00 " 960 "$1,283.10 " $916.50 "$1,466.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500466 PHYSICIAN FEE - CARDIAC CATH PF-PERQ TRANSCATH SEPTL REDUXN EACH 93583 "$2,055.00 " 960 "$1,438.50 " "$1,027.50 " "$1,644.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500334 PHYSICIAN FEE - CARDIAC CATH PF-PHARMACOLOGIC AGENT ADMIN EACH 93463 $250.00 960 $175.00 $125.00 $200.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501803 PHYSICIAN FEE - CARDIAC CATH PF-PM DEV INTERROGATE REMOTE EACH 93294 $76.00 960 $53.20 $38.00 $60.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500722 PHYSICIAN FEE - CARDIAC CATH PF-PRE/POST PROG EVAL MULTI LD EACH 93286 $37.00 960 $25.90 $18.50 $29.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500623 PHYSICIAN FEE - CARDIAC CATH PF-PRGRMG DEV EVAL IMPLTBL SYS EACH 93260 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500680 PHYSICIAN FEE - CARDIAC CATH PF-PRGRMG EVAL IMPLANT DFB SGL EACH 93282 $99.00 960 $69.30 $49.50 $79.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500706 PHYSICIAN FEE - CARDIAC CATH PF-PRGRMG EVL IMPLANT DFB MULT EACH 93284 $116.00 960 $81.20 $58.00 $92.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500714 PHYSICIAN FEE - CARDIAC CATH PF-PROG EVAL IMPLT LOOP RECORD EACH 93285 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500649 PHYSICIAN FEE - CARDIAC CATH PF-PROG EVAL PACEMKR 1 LEAD EACH 93279 $77.00 960 $53.90 $38.50 $61.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501720 PHYSICIAN FEE - CARDIAC CATH PF-PROG EVAL PACEMKR 1 LEAD EACH 93279 $77.00 960 $53.90 $38.50 $61.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501738 PHYSICIAN FEE - CARDIAC CATH PF-PROG EVAL PACEMKR DUAL LEAD EACH 93280 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501746 PHYSICIAN FEE - CARDIAC CATH PF-PROG EVAL PACEMKR MLTI LEAD EACH 93281 $103.00 960 $72.10 $51.50 $82.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500128 PHYSICIAN FEE - CARDIAC CATH PF-PRQ CARD REVASC MI 1 VSL EACH 92941 "$1,827.00 " 960 "$1,278.90 " $913.50 "$1,461.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500052 PHYSICIAN FEE - CARDIAC CATH PF-PRQ CARD STENT W/ANGIO 1VSL EACH 92928 "$1,628.00 " 960 "$1,139.60 " $814.00 "$1,302.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500060 PHYSICIAN FEE - CARDIAC CATH PF-PRQ CARD STENT W/ANGIO ADDL EACH 92929 $922.00 960 $645.40 $461.00 $737.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500003 PHYSICIAN FEE - CARDIAC CATH PF-PRQ CARDIAC ANGIO 1 ART EACH 92920 "$1,463.00 " 960 "$1,024.10 " $731.50 "$1,170.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500011 PHYSICIAN FEE - CARDIAC CATH PF-PRQ CARDIAC ANGIO ADDL ART EACH 92921 $830.00 960 $581.00 $415.00 $664.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500094 PHYSICIAN FEE - CARDIAC CATH PF-PRQ REVASC BYP GRAFT 1 VSL EACH 92937 "$1,629.00 " 960 "$1,140.30 " $814.50 "$1,303.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500219 PHYSICIAN FEE - CARDIAC CATH PF-PTC TRANSLUM CORONARY THRMB EACH 92973 $488.00 960 $341.60 $244.00 $390.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500292 PHYSICIAN FEE - CARDIAC CATH PF-PTPA ANGIOPLASTY EA VESSL EACH 92997 "$1,726.00 " 960 "$1,208.20 " $863.00 "$1,380.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500300 PHYSICIAN FEE - CARDIAC CATH PF-PUL ART BALLOON REPR PERCUT EACH 92998 $877.00 960 $613.90 $438.50 $701.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500417 PHYSICIAN FEE - CARDIAC CATH PF-PULMONARY ANGIO EACH 93568 $128.00 960 $89.60 $64.00 $102.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500912 PHYSICIAN FEE - CARDIAC CATH PF-R&L HEART CATH & CORONARIES EACH 93460 "$1,011.00 " 960 $707.70 $505.50 $808.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98565088 PHYSICIAN FEE - CARDIAC CATH PF-REM MNTR WRLS P-ART PRS SNR EACH 93264 $94.00 960 $65.80 $47.00 $75.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501837 PHYSICIAN FEE - CARDIAC CATH PF-REMOTE 30 DAY ECG REV/REPT EACH 93228 $64.00 960 $44.80 $32.00 $51.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501845 PHYSICIAN FEE - CARDIAC CATH PF-REMOTE 30 DAY ECG TECH SUPP EACH 93229 "$2,053.00 " 960 "$1,437.10 " "$1,026.50 " "$1,642.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500888 PHYSICIAN FEE - CARDIAC CATH PF-RHC CORONARIES & BYPASS GR EACH 93457 $946.00 960 $662.20 $473.00 $756.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500839 PHYSICIAN FEE - CARDIAC CATH PF-RIGHT & LEFT HEART CATH EACH 93453 $856.00 960 $599.20 $428.00 $684.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500813 PHYSICIAN FEE - CARDIAC CATH PF-RIGHT HEART CATH EACH 93451 $351.00 960 $245.70 $175.50 $280.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500862 PHYSICIAN FEE - CARDIAC CATH PF-RIGHT HEART CATH & CORO EACH 93456 $844.00 960 $590.80 $422.00 $675.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501068 PHYSICIAN FEE - CARDIAC CATH PF-RIGHT VENTRICULAR RECORDING EACH 93603 $220.00 960 $154.00 $110.00 $176.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501191 PHYSICIAN FEE - CARDIAC CATH PF-STIMULATION PACING HEART EACH 93623 $180.00 960 $126.00 $90.00 $144.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500409 PHYSICIAN FEE - CARDIAC CATH PF-SUPRAVALVULAR AORTOGRAPHY EACH 93567 $105.00 960 $73.50 $52.50 $84.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500151 PHYSICIAN FEE - CARDIAC CATH PF-TEMPORARY EXTERNAL PACING EACH 92953 $4.00 960 $2.80 $2.00 $3.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501274 PHYSICIAN FEE - CARDIAC CATH PF-TILT TABLE EVALUATION EACH 93660 $186.00 960 $130.20 $93.00 $148.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500532 PHYSICIAN FEE - CARDIAC CATH PF-TX ATRIAL FIB PULM VEIN ISO EACH 93656 "$2,612.00 " 960 "$1,828.40 " "$1,306.00 " "$2,089.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500540 PHYSICIAN FEE - CARDIAC CATH PF-TX L/R ATRIAL FIB ADDL EACH 93657 $845.00 960 $591.50 $422.50 $676.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500581 PHYSICIAN FEE - CARDIAC CATH PF-US INTRAVASC EA ADD VESL EACH 92979 $203.00 960 $142.10 $101.50 $162.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97500573 PHYSICIAN FEE - CARDIAC CATH PF-US INTRAVASC INIT VESSEL EACH 92978 $257.00 960 $179.90 $128.50 $205.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400204 PHYSICIAN FEE - CARDIOLOGY PF-AMB BP MON 24 HR R/S/I&R EACH 93784 $118.00 960 $82.60 $59.00 $94.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400238 PHYSICIAN FEE - CARDIOLOGY PF-AMBULATORY BP ANLYS EACH 93788 $16.00 960 $11.20 $8.00 $12.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400220 PHYSICIAN FEE - CARDIOLOGY PF-AMBULATORY BP RECORDING EACH 93786 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400550 PHYSICIAN FEE - CARDIOLOGY PF-ANLYS PCMKR ANTITACHYCARDIA EACH 93724 $118.00 960 $82.60 $59.00 $94.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400261 PHYSICIAN FEE - CARDIOLOGY PF-CARDIAC REHAB W/EKG SESSION EACH 93798 $35.00 960 $24.50 $17.50 $28.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400253 PHYSICIAN FEE - CARDIOLOGY PF-CARDIAC REHAB W/O EKG SESS EACH 93797 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400030 PHYSICIAN FEE - CARDIOLOGY PF-CARDIOVASCULAR STRESS TEST EACH 93016 $53.00 960 $37.10 $26.50 $42.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400055 PHYSICIAN FEE - CARDIOLOGY PF-CARDIOVASCULAR STRESS TEST EACH 93018 $35.00 960 $24.50 $17.50 $28.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400790 PHYSICIAN FEE - CARDIOLOGY PF-CARDIOVERSION EACH 92960 $276.00 960 $193.20 $138.00 $220.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400105 PHYSICIAN FEE - CARDIOLOGY PF-DEV INTERROG REMOTE 1/2/MLT EACH 93295 $94.00 960 $65.80 $47.00 $75.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400329 PHYSICIAN FEE - CARDIOLOGY PF-DOPPLER ECG FETAL EACH 76827 $70.00 960 $49.00 $35.00 $56.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400337 PHYSICIAN FEE - CARDIOLOGY PF-DOPPLER ECG FETL REPEAT FUP EACH 76828 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400303 PHYSICIAN FEE - CARDIOLOGY PF-ECG FETAL HEART EACH 76825 $198.00 960 $138.60 $99.00 $158.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400311 PHYSICIAN FEE - CARDIOLOGY PF-ECG FETL HEART F/UP REPEAT EACH 76826 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400402 PHYSICIAN FEE - CARDIOLOGY PF-ECHO 2D W/W/O M-MODE CMPL EACH 93307 $108.00 960 $75.60 $54.00 $86.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400410 PHYSICIAN FEE - CARDIOLOGY PF-ECHO 2D W/W/O M-MODE LTD EACH 93308 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400519 PHYSICIAN FEE - CARDIOLOGY PF-ECHO COLOR FLOW MAPPING EACH 93325 $8.00 960 $5.60 $4.00 $6.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400386 PHYSICIAN FEE - CARDIOLOGY PF-ECHO CONGENITAL ANOMALY LTD EACH 93304 $90.00 960 $63.00 $45.00 $72.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400378 PHYSICIAN FEE - CARDIOLOGY PF-ECHO CONGENITAL ANOMLY CMPL EACH 93303 $153.00 960 $107.10 $76.50 $122.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400485 PHYSICIAN FEE - CARDIOLOGY PF-ECHO DOPPLER CMPL EACH 93320 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400501 PHYSICIAN FEE - CARDIOLOGY PF-ECHO DOPPLER LTD EACH 93321 $19.00 960 $13.30 $9.50 $15.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400527 PHYSICIAN FEE - CARDIOLOGY PF-ECHO REST & STRESS W/PF EACH 93350 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400436 PHYSICIAN FEE - CARDIOLOGY PF-ECHO TEE (TRANSESOPHGEAL) EACH 93312 $264.00 960 $184.80 $132.00 $211.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400451 PHYSICIAN FEE - CARDIOLOGY PF-ECHO TEE ANOMALY CMPL W/PF EACH 93315 $313.00 960 $219.10 $156.50 $250.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400469 PHYSICIAN FEE - CARDIOLOGY PF-ECHO TEE ANOMALY IMAGE W/PF EACH 93317 $223.00 960 $156.10 $111.50 $178.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400170 PHYSICIAN FEE - CARDIOLOGY PF-ECHO TEE ANOMALY PROBE PLMT EACH 93316 $67.00 960 $46.90 $33.50 $53.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400477 PHYSICIAN FEE - CARDIOLOGY PF-ECHO TEE MONITORING EACH 93318 $256.00 960 $179.20 $128.00 $204.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400162 PHYSICIAN FEE - CARDIOLOGY PF-ECHO TRANSESOPHAGEAL EACH 93313 $29.00 960 $20.30 $14.50 $23.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400188 PHYSICIAN FEE - CARDIOLOGY PF-ECHO TRANSESOPHAGEAL (TEE) EACH 93355 $572.00 960 $400.40 $286.00 $457.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400444 PHYSICIAN FEE - CARDIOLOGY PF-ECHO TRANSESOPHAGEAL REPORT EACH 93314 $229.00 960 $160.30 $114.50 $183.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400733 PHYSICIAN FEE - CARDIOLOGY PF-ECHO TTE W/CONTRAST EACH 93306 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400626 PHYSICIAN FEE - CARDIOLOGY PF-EKG INITIAL PREVENT EXAM EACH G0403 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400659 PHYSICIAN FEE - CARDIOLOGY PF-EKG INTERP & REPORT PREVENT EACH G0405 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400089 PHYSICIAN FEE - CARDIOLOGY PF-EKG RHYTHM TRACING ONLY EACH 93041 $17.00 960 $11.90 $8.50 $13.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400345 PHYSICIAN FEE - CARDIOLOGY PF-EKG SIGNAL AVERAGED EACH 93278 $32.00 960 $22.40 $16.00 $25.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400543 PHYSICIAN FEE - CARDIOLOGY PF-EXERCISE W/HEMODYNAMIC MEAS EACH 93464 $224.00 960 $156.80 $112.00 $179.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400824 PHYSICIAN FEE - CARDIOLOGY PF-EXT ECG>48HR<7D SCAN A/R EACH 93243 $563.00 960 $394.10 $281.50 $450.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400592 PHYSICIAN FEE - CARDIOLOGY "PF-EXTRNL COUNTERPULSE, PER TX" EACH G0166 $262.00 960 $183.40 $131.00 $209.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400121 PHYSICIAN FEE - CARDIOLOGY PF-ICM DEVICE INTERROG REMOTE EACH 93297 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400139 PHYSICIAN FEE - CARDIOLOGY PF-ILR DEVICE INTERROG REMOTE EACH 93298 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400675 PHYSICIAN FEE - CARDIOLOGY PF-INTENS CARD REHAB NO EXER EACH G0423 $330.00 960 $231.00 $165.00 $264.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400667 PHYSICIAN FEE - CARDIOLOGY PF-INTENS CARD REHAB W/EXERC EACH G0422 $330.00 960 $231.00 $165.00 $264.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400196 PHYSICIAN FEE - CARDIOLOGY PF-INTERROGATION VAD IN PERSON EACH 93750 $108.00 960 $75.60 $54.00 $86.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400642 PHYSICIAN FEE - CARDIOLOGY PF-MEDICARE-1ST PREVENTIVE EKG EACH G0404 $17.00 960 $11.90 $8.50 $13.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400295 PHYSICIAN FEE - CARDIOLOGY PF-PHLEBOTOMY THERAPEUTIC EACH 99195 $246.00 960 $172.20 $123.00 $196.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400113 PHYSICIAN FEE - CARDIOLOGY PF-PM/ICD REMOTE TECH SERV EACH 93296 $55.00 960 $38.50 $27.50 $44.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400246 PHYSICIAN FEE - CARDIOLOGY PF-REVIEW/REPORT BP RECORDING EACH 93790 $45.00 960 $31.50 $22.50 $36.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400063 PHYSICIAN FEE - CARDIOLOGY PF-RHYTHM ECG WITH REPORT EACH 93040 $35.00 960 $24.50 $17.50 $28.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400576 PHYSICIAN FEE - CARDIOLOGY PF-SET-UP CARDIOVERT-DEFIBRILL EACH 93745 $95.00 960 $66.50 $47.50 $76.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400048 PHYSICIAN FEE - CARDIOLOGY PF-STRESS TEST EACH 93017 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400535 PHYSICIAN FEE - CARDIOLOGY PF-STRESS TTE COMPLETE EACH 93351 $206.00 960 $144.20 $103.00 $164.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400584 PHYSICIAN FEE - CARDIOLOGY PF-TRANSTHOR 2D LIMITED W/CONT EACH C8924 $167.00 960 $116.90 $83.50 $133.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400808 PHYSICIAN FEE - CARDIOLOGY PF-USE OF CONTRAST W ECHO EACH 93552 $89.00 480 $62.30 $44.50 $71.20 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 97400014 PHYSICIAN FEE - CARDIOLOGY THROMBOLYSIS INTRACORONARY INF EACH 92975 "$1,042.00 " 960 $729.40 $521.00 $833.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97400022 PHYSICIAN FEE - CARDIOLOGY THROMBOLYSIS INTRAVENOUS INF EACH 92977 $151.00 960 $105.70 $75.50 $120.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525843 PHYSICIAN FEE - CLINIC PF-ACID PERFUSION OF ESOPHAGUS EACH 91030 $115.00 960 $80.50 $57.50 $92.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561061 PHYSICIAN FEE - CLINIC PF-ACTINOTHERAPY-UV LIGHT EACH 96900 $64.00 960 $44.80 $32.00 $51.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98522584 PHYSICIAN FEE - CLINIC PF-ACUP W/O STIMUL 15 MIN RVU EACH 97810 $0.00 960 $0.00 $0.00 $0.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98522592 PHYSICIAN FEE - CLINIC PF-ACUP W/O STIMUL ADD 15M RVU EACH 97811 $0.00 960 $0.00 $0.00 $0.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98522618 PHYSICIAN FEE - CLINIC PF-ACUP W/STIMUL ADDL 15M RVU EACH 97814 $0.00 960 $0.00 $0.00 $0.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563927 PHYSICIAN FEE - CLINIC PF-ADULT DEPRESSION SCREEN EACH G0444 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563760 PHYSICIAN FEE - CLINIC PF-ADVANCED CARE PLAN + 30 EACH 99498 $183.00 960 $128.10 $91.50 $146.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563752 PHYSICIAN FEE - CLINIC PF-ADVANCED CARE PLAN-30 EACH 99497 $194.00 960 $135.80 $97.00 $155.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526221 PHYSICIAN FEE - CLINIC PF-ALLERGY PATCH TESTS EACH 95044 $14.00 960 $9.80 $7.00 $11.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525116 PHYSICIAN FEE - CLINIC PF-ALLERGY TESTING WITH DRUGS EACH 95018 $19.00 960 $13.30 $9.50 $15.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525108 PHYSICIAN FEE - CLINIC PF-ALLERGY TESTING WITH VENOMS EACH 95017 $10.00 960 $7.00 $5.00 $8.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98565112 PHYSICIAN FEE - CLINIC PF-ALYS CPLX CN NPGT PRGRMG EACH 95977 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98565104 PHYSICIAN FEE - CLINIC PF-ALYS SMPL CN NPGT PRGRMG EACH 95976 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561038 PHYSICIAN FEE - CLINIC PF-ANLS NEUR CPLX 1ST H W/ EACH 95972 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561012 PHYSICIAN FEE - CLINIC PF-ANLYS NEUR W/O PROG SMP EACH 95970 $48.00 960 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561020 PHYSICIAN FEE - CLINIC PF-ANLYS NEUR W/PROG SMP EACH 95971 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558885 PHYSICIAN FEE - CLINIC PF-ANLYS PAIN PUMP W/PROG EACH 62368 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563901 PHYSICIAN FEE - CLINIC PF-ANNUAL ALCOHOL SCR 15 EACH G0442 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526056 PHYSICIAN FEE - CLINIC PF-ANORECTAL MANOMETRY EACH 91122 $222.00 960 $155.40 $111.00 $177.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557697 PHYSICIAN FEE - CLINIC PF-ANOSCOPY - W/ABLATION EACH 46615 $243.00 960 $170.10 $121.50 $194.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559958 PHYSICIAN FEE - CLINIC PF-ANTERIOR CHAMBER - MEDS EACH 66030 $285.00 960 $199.50 $142.50 $228.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563521 PHYSICIAN FEE - CLINIC PF-ANTICOAG MGT PT WARFARIN EACH 95249 $168.00 960 $117.60 $84.00 $134.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525033 PHYSICIAN FEE - CLINIC PF-ANTIGEN 1 STINGING INSECT EACH 95145 $9.00 960 $6.30 $4.50 $7.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525041 PHYSICIAN FEE - CLINIC PF-ANTIGEN 2 STINGING INSECTS EACH 95146 $9.00 960 $6.30 $4.50 $7.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525058 PHYSICIAN FEE - CLINIC PF-ANTIGEN 3 STINGING INSECTS EACH 95147 $9.00 960 $6.30 $4.50 $7.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525066 PHYSICIAN FEE - CLINIC PF-ANTIGEN 4 STINGING INSECTS EACH 95148 $9.00 960 $6.30 $4.50 $7.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525074 PHYSICIAN FEE - CLINIC PF-ANTIGEN 5 STINGING INSECTS EACH 95149 $9.00 960 $6.30 $4.50 $7.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525090 PHYSICIAN FEE - CLINIC PF-ANTIGEN BITING INSECT EACH 95170 $9.00 960 $6.30 $4.50 $7.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525025 PHYSICIAN FEE - CLINIC PF-ANTIGEN TX SINGLE DOSE EACH 95144 $10.00 960 $7.00 $5.00 $8.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525082 PHYSICIAN FEE - CLINIC PF-ANTIGEN TX SINGLE/MULTIPLE EACH 95165 $10.00 960 $7.00 $5.00 $8.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556715 PHYSICIAN FEE - CLINIC PF-APPL LONG LEG SPLINT EACH 29505 $142.00 960 $99.40 $71.00 $113.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562689 PHYSICIAN FEE - CLINIC PF-APPLY BODY CAST SH HIPS EACH 29035 $393.00 960 $275.10 $196.50 $314.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556483 PHYSICIAN FEE - CLINIC PF-APPLY CAST - LONG ARM EACH 29065 $186.00 960 $130.20 $93.00 $148.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556491 PHYSICIAN FEE - CLINIC PF-APPLY CAST - SHORT ARM EACH 29075 $170.00 960 $119.00 $85.00 $136.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556707 PHYSICIAN FEE - CLINIC PF-APPLY CLUBFOOT CAST W/M EACH 29450 $299.00 960 $209.30 $149.50 $239.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562663 PHYSICIAN FEE - CLINIC PF-APPLY HALO TYPE BODY CST EACH 29010 $437.00 960 $305.90 $218.50 $349.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556590 PHYSICIAN FEE - CLINIC PF-APPLY HIP SPICA CAST 1 EACH 29305 $432.00 960 $302.40 $216.00 $345.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556608 PHYSICIAN FEE - CLINIC PF-APPLY HIP SPICA CAST BO EACH 29325 $484.00 960 $338.80 $242.00 $387.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556616 PHYSICIAN FEE - CLINIC PF-APPLY LONG LEG CAST EACH 29345 $269.00 960 $188.30 $134.50 $215.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556673 PHYSICIAN FEE - CLINIC PF-APPLY PATELLAR CAST EACH 29435 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562671 PHYSICIAN FEE - CLINIC PF-APPLY RISSER BODY/HD EACH 29015 $493.00 960 $345.10 $246.50 $394.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553845 PHYSICIAN FEE - CLINIC PF-ARTHROCENT ASP/INJ JT M EACH 20610 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553829 PHYSICIAN FEE - CLINIC PF-ARTHROCENT ASP/INJ JT MD EACH 20605 $99.00 960 $69.30 $49.50 $79.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555030 PHYSICIAN FEE - CLINIC PF-ARTHROTOMY W BX INTERPH EACH 28054 $612.00 960 $428.40 $306.00 $489.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551393 PHYSICIAN FEE - CLINIC PF-ASP FINE NDL W/O IMAGIN EACH 10021 $147.00 960 $102.90 $73.50 $117.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560287 PHYSICIAN FEE - CLINIC PF-ASP ORBITAL CONTENTS EACH 67415 $263.00 960 $184.10 $131.50 $210.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563273 PHYSICIAN FEE - CLINIC PF-BIOFEEDBCK TRAIN ANY EACH 90901 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560782 PHYSICIAN FEE - CLINIC PF-BIOPSY LACRIMAL GLAND EACH 68510 $734.00 960 $513.80 $367.00 $587.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557424 PHYSICIAN FEE - CLINIC "PF-BIOPSY OF PALATE, UVULA " EACH 42100 $292.00 960 $204.40 $146.00 $233.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558109 PHYSICIAN FEE - CLINIC PF-BIOPSY OF PROSTATE EACH 55700 $346.00 960 $242.20 $173.00 $276.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557341 PHYSICIAN FEE - CLINIC PF-BIOPSY OF TONGUE EACH 41100 $285.00 960 $199.50 $142.50 $228.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556889 PHYSICIAN FEE - CLINIC "PF-BIOPSY, INTRANASAL " EACH 30100 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557325 PHYSICIAN FEE - CLINIC "PF-BIOPSY, VESTIBULE OF MO " EACH 40808 $235.00 960 $164.50 $117.50 $188.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557127 PHYSICIAN FEE - CLINIC PF-BL DRAW < 3 YRS SCALP V EACH 36405 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563919 PHYSICIAN FEE - CLINIC PF-BR ALCOHOL MISUSE COUNS EACH G0443 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525215 PHYSICIAN FEE - CLINIC PF-BREATH HYDROGEN TEST EACH 91065 $25.00 960 $17.50 $12.50 $20.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98539356 PHYSICIAN FEE - CLINIC PF-BRIEF CHECK IN BY MD/QHP EACH G2012 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98500275 PHYSICIAN FEE - CLINIC PF-BRIEF CHECK IN MD 11-20 MIN EACH G2252 $64.00 960 $44.80 $32.00 $51.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557234 PHYSICIAN FEE - CLINIC PF-BX BONE MARROW NEEDLE EACH 38221 $181.00 960 $126.70 $90.50 $144.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553597 PHYSICIAN FEE - CLINIC PF-BX BREAST NDL 1 LES BI EACH 19100 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553647 PHYSICIAN FEE - CLINIC PF-BX BRST W/LOC + LES MAM EACH 19282 $128.00 960 $89.60 $64.00 $102.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553639 PHYSICIAN FEE - CLINIC PF-BX BRST W/LOC 1 LES MAM EACH 19281 $255.00 960 $178.50 $127.50 $204.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558471 PHYSICIAN FEE - CLINIC PF-BX ENDOMETRIAL SAMPL W/ EACH 58100 $173.00 960 $121.10 $86.50 $138.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557457 PHYSICIAN FEE - CLINIC PF-BX GLAND SALIVARY INCIS EACH 42405 $609.00 960 $426.30 $304.50 $487.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557440 PHYSICIAN FEE - CLINIC PF-BX GLAND SALIVARY NEEDL EACH 42400 $138.00 960 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558273 PHYSICIAN FEE - CLINIC PF-BX MUCOSA VAGINAL SMP EACH 57100 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553738 PHYSICIAN FEE - CLINIC PF-BX MUSCLE SUPERFICIAL EACH 20200 $268.00 960 $187.60 $134.00 $214.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558117 PHYSICIAN FEE - CLINIC PF-BX PROSTATE INCISIONAL EACH 55705 $703.00 960 $492.10 $351.50 $562.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98565534 PHYSICIAN FEE - CLINIC PF-C REM SUTR & STAPL WO ANES EACH 15854 $42.00 960 $29.40 $21.00 $33.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98565526 PHYSICIAN FEE - CLINIC PF-C REM SUTR OR STAPL WO ANES EACH 15853 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360720 PHYSICIAN FEE - CLINIC PF-CA SCREEN FLEX SIGMOIDSCOPE EACH G0104 $151.00 960 $105.70 $75.50 $120.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563877 PHYSICIAN FEE - CLINIC PF-CA SCREEN-PELV/BREAST EX EACH G0101 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557754 PHYSICIAN FEE - CLINIC PF-CATH FLUID PERI/RETRO EACH 49406 $503.00 960 $352.10 $251.50 $402.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553316 PHYSICIAN FEE - CLINIC PF-CAUT CHEM TISSUE GRAN EACH 17250 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562259 PHYSICIAN FEE - CLINIC PF-CERVICOPLASTY EACH 15819 "$2,164.00 " 960 "$1,514.80 " "$1,082.00 " "$1,731.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557499 PHYSICIAN FEE - CLINIC PF-CHANGE GASTROSTOMY TUBE EACH 43762 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553159 PHYSICIAN FEE - CLINIC PF-CHEM PEEL NON-FACIAL EP EACH 15792 $550.00 960 $385.00 $275.00 $440.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560261 PHYSICIAN FEE - CLINIC PF-CHEMODEN MUSCLE XOCULAR EACH 67345 $572.00 960 $400.40 $286.00 $457.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557887 PHYSICIAN FEE - CLINIC PF-CHG TUBE CYSTOSTOMY SMP EACH 51705 $137.00 960 $95.90 $68.50 $109.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557036 PHYSICIAN FEE - CLINIC PF-CHG TUBE TRACHEOTOMY EACH 31502 $94.00 960 $65.80 $47.00 $75.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98565518 PHYSICIAN FEE - CLINIC PF-CHRNC CARE MGT PHYS 1ST 30 EACH 99491 $194.00 960 $135.80 $97.00 $155.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558059 PHYSICIAN FEE - CLINIC PF-CIRC W/O CLAMP >28 DAYS EACH 54161 $524.00 960 $366.80 $262.00 $419.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554017 PHYSICIAN FEE - CLINIC PF-CL TX PALATAL/ MAXI FRA EACH 21421 "$1,408.00 " 960 $985.60 $704.00 "$1,126.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552771 PHYSICIAN FEE - CLINIC PF-CMPLX RPR S/A/L + 5 CM/ EACH 13122 $222.00 960 $155.40 $111.00 $177.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552755 PHYSICIAN FEE - CLINIC PF-CMPLX RPR S/A/L 1.1-2.5 EACH 13120 $608.00 960 $425.60 $304.00 $486.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556954 PHYSICIAN FEE - CLINIC PF-CNTRL NOSEBLEED ANT CPL EACH 30903 $212.00 960 $148.40 $106.00 $169.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556947 PHYSICIAN FEE - CLINIC PF-CNTRL NOSEBLEED ANT SMP EACH 30901 $156.00 960 $109.20 $78.00 $124.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556970 PHYSICIAN FEE - CLINIC PF-CNTRL NOSEBLEED SUBSEQ EACH 30906 $361.00 960 $252.70 $180.50 $288.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526163 PHYSICIAN FEE - CLINIC PF-COLON MOTILITY 6 HR STUDY EACH 91117 $348.00 960 $243.60 $174.00 $278.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558323 PHYSICIAN FEE - CLINIC PF-COLOPERINEOR NON-OB EACH 57210 "$1,069.00 " 960 $748.30 $534.50 $855.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558315 PHYSICIAN FEE - CLINIC PF-COLPORRHAPHY NON-OB EACH 57200 $900.00 960 $630.00 $450.00 $720.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558455 PHYSICIAN FEE - CLINIC PF-CONE CERVIX KNIFE/LASER EACH 57520 $806.00 960 $564.20 $403.00 $644.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563612 PHYSICIAN FEE - CLINIC PF-CONSULTATION LVL 2 EACH 99242 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563620 PHYSICIAN FEE - CLINIC PF-CONSULTATION LVL 3 EACH 99243 $216.00 960 $151.20 $108.00 $172.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563638 PHYSICIAN FEE - CLINIC PF-CONSULTATION LVL 4 EACH 99244 $349.00 960 $244.30 $174.50 $279.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563646 PHYSICIAN FEE - CLINIC PF-CONSULTATION LVL 5 EACH 99245 $475.00 960 $332.50 $237.50 $380.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555675 PHYSICIAN FEE - CLINIC PF-CORRECT BUN-KELLER/MCB/ EACH 28292 "$1,284.00 " 960 $898.80 $642.00 "$1,027.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560824 PHYSICIAN FEE - CLINIC PF-CORRECT EVERTED PUNCTUM EACH 68705 $424.00 960 $296.80 $212.00 $339.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98565542 PHYSICIAN FEE - CLINIC PF-C-PT-FOCUSED HLTH RISK ASMT EACH 96160 $8.00 960 $5.60 $4.00 $6.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556731 PHYSICIAN FEE - CLINIC PF-CR-STRAPPING ANKLE/FOOT EACH 29540 $45.00 960 $31.50 $22.50 $36.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556574 PHYSICIAN FEE - CLINIC PF-CR-STRAPPING SHOULDER EACH 29240 $46.00 960 $32.20 $23.00 $36.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553555 PHYSICIAN FEE - CLINIC PF-CRYOTHERAPY ACNE EACH 17340 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557903 PHYSICIAN FEE - CLINIC PF-CYSTOMETROGRAM/CMG CPLX EACH 51726 $218.00 960 $152.60 $109.00 $174.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557960 PHYSICIAN FEE - CLINIC PF-CYSTOSCOPY EACH 52281 $401.00 960 $280.70 $200.50 $320.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557978 PHYSICIAN FEE - CLINIC PF-CYSTOSCOPY W REM ST/FB EACH 52310 $400.00 960 $280.00 $200.00 $320.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558497 PHYSICIAN FEE - CLINIC PF-D&C NON-OB EACH 58120 $636.00 960 $445.20 $318.00 $508.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560956 PHYSICIAN FEE - CLINIC PF-DEBR MASTOID CAVITY SMP EACH 69220 $138.00 960 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561152 PHYSICIAN FEE - CLINIC PF-DEBR OPEN WOUND ADDL 20 EACH 97598 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551518 PHYSICIAN FEE - CLINIC PF-DEBR SKIN 10% BODY SURF EACH 11000 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551526 PHYSICIAN FEE - CLINIC PF-DEBR SKIN EA ADD 10% BO EACH 11001 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551534 PHYSICIAN FEE - CLINIC PF-DEBRIDE SKIN AT FX SITE EACH 11010 $747.00 960 $522.90 $373.50 $597.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563208 PHYSICIAN FEE - CLINIC PF-DECOMP DISK LUMBAR PERC EACH 62287 "$1,582.00 " 960 "$1,107.40 " $791.00 "$1,265.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553068 PHYSICIAN FEE - CLINIC PF-DELAY FLAP EYE/NOS/EAR/ EACH 15630 $910.00 960 $637.00 $455.00 $728.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553118 PHYSICIAN FEE - CLINIC PF-DERMABRASION NOT FACE EACH 15782 $965.00 960 $675.50 $482.50 $772.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553126 PHYSICIAN FEE - CLINIC PF-DERMABRASION SUPERFICIA EACH 15783 $927.00 960 $648.90 $463.50 $741.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559867 PHYSICIAN FEE - CLINIC PF-DEST LES CORNEA CRYO/PH EACH 65450 $826.00 960 $578.20 $413.00 $660.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553449 PHYSICIAN FEE - CLINIC PF-DEST LES FACE/EAR TO 0. EACH 17280 $228.00 960 $159.60 $114.00 $182.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560436 PHYSICIAN FEE - CLINIC PF-DEST LES-LID MARGN <1CM EACH 67850 $339.00 960 $237.30 $169.50 $271.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553456 PHYSICIAN FEE - CLINIC PF-DEST LESN FACE/EAR .6-1 EACH 17281 $310.00 960 $217.00 $155.00 $248.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553464 PHYSICIAN FEE - CLINIC PF-DEST LESN FACE/EAR 1.1- EACH 17282 $357.00 960 $249.90 $178.50 $285.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553472 PHYSICIAN FEE - CLINIC PF-DEST LESN FACE/EAR 2.1- EACH 17283 $448.00 960 $313.60 $224.00 $358.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553480 PHYSICIAN FEE - CLINIC PF-DEST LESN FACE/EAR 3.1- EACH 17284 $521.00 960 $364.70 $260.50 $416.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558018 PHYSICIAN FEE - CLINIC PF-DEST LESN PENIS SMP CHE EACH 54050 $282.00 960 $197.40 $141.00 $225.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553266 PHYSICIAN FEE - CLINIC PF-DEST LESN PREMALIG 1ST EACH 17000 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553357 PHYSICIAN FEE - CLINIC PF-DEST LESN TRNK/ARM 2.1- EACH 17263 $320.00 960 $224.00 $160.00 $256.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553373 PHYSICIAN FEE - CLINIC PF-DEST LESN TRUNK/ARM >4. EACH 17266 $401.00 960 $280.70 $200.50 $320.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558257 PHYSICIAN FEE - CLINIC PF-DEST LESN VAGINA SMP EACH 57061 $310.00 960 $217.00 $155.00 $248.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553290 PHYSICIAN FEE - CLINIC PF-DEST LESN VASCULAR <10C EACH 17106 $727.00 960 $508.90 $363.50 $581.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562309 PHYSICIAN FEE - CLINIC PF-DEST LESN VASCULAR >50CM EACH 17108 "$1,403.00 " 960 $982.10 $701.50 "$1,122.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560048 PHYSICIAN FEE - CLINIC PF-DISCIS CATARACT SEC LAS EACH 66821 $794.00 960 $555.80 $397.00 $635.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562895 PHYSICIAN FEE - CLINIC PF-DRAIN ABSC SUBMAXILL EXT EACH 42320 $481.00 960 $336.70 $240.50 $384.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557309 PHYSICIAN FEE - CLINIC PF-DRAIN ABSC/CYST MOUTH LES EACH 40800 $309.00 960 $216.30 $154.50 $247.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556863 PHYSICIAN FEE - CLINIC PF-DRAIN ABSC/HEMAT NASAL EACH 30000 $324.00 960 $226.80 $162.00 $259.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557432 PHYSICIAN FEE - CLINIC PF-DRAIN SALIVARY GLAND EACH 42310 $353.00 960 $247.10 $176.50 $282.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553837 PHYSICIAN FEE - CLINIC PF-DRAIN/INJ MED JT/BURSA EACH 20606 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553811 PHYSICIAN FEE - CLINIC PF-DRAIN/INJ SM JT/BURSA W EACH 20604 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559909 PHYSICIAN FEE - CLINIC PF-DRAINAGE OF EYE W/DX AS EACH 65800 $229.00 960 $160.30 $114.50 $183.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558083 PHYSICIAN FEE - CLINIC PF-DRAINAGE OF SCROTUM EACH 54700 $571.00 960 $399.70 $285.50 $456.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553209 PHYSICIAN FEE - CLINIC PF-DRESSING CHANGE W/ANES EACH 15852 $122.00 960 $85.40 $61.00 $97.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559495 PHYSICIAN FEE - CLINIC PF-DSTR NULYT AGT GNCLR NR EACH 64624 $381.00 960 $266.70 $190.50 $304.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525967 PHYSICIAN FEE - CLINIC PF-DUODENAL MOTILITY STUDY EACH 91022 $181.00 960 $126.70 $90.50 $144.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525538 PHYSICIAN FEE - CLINIC PF-ELECTROGASTROGRAPHY EACH 91132 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525645 PHYSICIAN FEE - CLINIC PF-ELECTROGASTROGRAPHY W/TEST EACH 91133 $82.00 960 $57.40 $41.00 $65.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556996 PHYSICIAN FEE - CLINIC PF-ENDO NASAL DIAGNOSTIC EACH 31231 $174.00 960 $121.80 $87.00 $139.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557002 PHYSICIAN FEE - CLINIC PF-ENDO NASAL DX W/MAX SIN EACH 31233 $364.00 960 $254.80 $182.00 $291.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560584 PHYSICIAN FEE - CLINIC PF-ENTROPION REPAIR EXTENS EACH 67924 "$1,167.00 " 960 $816.90 $583.50 $933.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525777 PHYSICIAN FEE - CLINIC PF-ESOPH BALLOON DISTENS TST EACH 91040 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525835 PHYSICIAN FEE - CLINIC PF-ESOPH CAPSULE ENDOSCOPY EACH 91111 $113.00 960 $79.10 $56.50 $90.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525850 PHYSICIAN FEE - CLINIC PF-ESOPH IMPED FUNCT TST > 1HR EACH 91038 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525785 PHYSICIAN FEE - CLINIC PF-ESOPH IMPED FUNCTION TEST EACH 91037 $122.00 960 $85.40 $61.00 $97.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525199 PHYSICIAN FEE - CLINIC PF-ESOPHGL MOTIL W/STIM/PERFUS EACH 91013 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563513 PHYSICIAN FEE - CLINIC PF-ESRD HOME PT P DAY 20+ EACH 90970 $25.00 960 $17.50 $12.50 $20.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559719 PHYSICIAN FEE - CLINIC PF-EVIS OCULAR CONTENT EACH 65091 "$1,898.00 " 960 "$1,328.60 " $949.00 "$1,518.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553621 PHYSICIAN FEE - CLINIC PF-EXC BREAST CYST/FIBRO/T EACH 19120 "$1,173.00 " 960 $821.10 $586.50 $938.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560360 PHYSICIAN FEE - CLINIC PF-EXC CHALAZION SGL EACH 67800 $262.00 960 $183.40 $131.00 $209.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554074 PHYSICIAN FEE - CLINIC PF-EXC CHEST WALL TUMOR EACH 21601 "$3,227.00 " 960 "$2,258.90 " "$1,613.50 " "$2,581.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562796 PHYSICIAN FEE - CLINIC PF-EXC CYST DERMOID SUBQ EACH 30124 $808.00 960 $565.60 $404.00 $646.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554967 PHYSICIAN FEE - CLINIC PF-EXC FT/TOE TUM DEP 1.5C EACH 28041 "$1,202.00 " 960 $841.40 $601.00 $961.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559800 PHYSICIAN FEE - CLINIC PF-EXC LESN CORNEA EACH 65400 "$1,541.00 " 960 "$1,078.70 " $770.50 "$1,232.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552284 PHYSICIAN FEE - CLINIC PF-EXC NAIL & MATRIX EACH 11750 $265.00 960 $185.50 $132.50 $212.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559826 PHYSICIAN FEE - CLINIC PF-EXC PTERYGIUM W/O GRAFT EACH 65420 $973.00 960 $681.10 $486.50 $778.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557374 PHYSICIAN FEE - CLINIC PF-EXC TONGUE LES W/CLOSUR EACH 41112 $640.00 960 $448.00 $320.00 $512.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557366 PHYSICIAN FEE - CLINIC PF-EXC TONGUE LES WO CLOSU EACH 41110 $345.00 960 $241.50 $172.50 $276.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552326 PHYSICIAN FEE - CLINIC PF-EXC WEDGE SKIN NAIL FOL EACH 11765 $242.00 960 $169.40 $121.00 $193.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557408 PHYSICIAN FEE - CLINIC PF-EXCISE GUM LESION EACH 41826 $508.00 960 $355.60 $254.00 $406.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526296 PHYSICIAN FEE - CLINIC PF-EXHALED NITRIC OXIDE MEAS EACH 95012 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563240 PHYSICIAN FEE - CLINIC PF-EXPRSS FOLLICLE CONJUNCT EACH 68040 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560055 PHYSICIAN FEE - CLINIC PF-EXTRACT LENS EACH 66940 "$2,004.00 " 960 "$1,402.80 " "$1,002.00 " "$1,603.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526320 PHYSICIAN FEE - CLINIC PF-EYE ALLERGY TESTS EACH 95060 $100.00 960 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525280 PHYSICIAN FEE - CLINIC PF-FIBROSCAN EACH 91200 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559966 PHYSICIAN FEE - CLINIC PF-FISTULIZATION OF SCLERA EACH 66170 "$2,798.00 " 960 "$1,958.60 " "$1,399.00 " "$2,238.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551344 PHYSICIAN FEE - CLINIC PF-FNA W FLUORO GUIDE EA A EACH 10008 $138.00 960 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559974 PHYSICIAN FEE - CLINIC PF-FOLLOW-UP SURGERY EYE EACH 66250 "$1,423.00 " 960 $996.10 $711.50 "$1,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556350 PHYSICIAN FEE - CLINIC PF-FUSION OF FT BONES-ANTH EACH 28725 "$2,109.00 " 960 "$1,476.30 " "$1,054.50 " "$1,687.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525959 PHYSICIAN FEE - CLINIC PF-GASTRIC MOTILITY STUDIES EACH 91020 $181.00 960 $126.70 $90.50 $144.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525769 PHYSICIAN FEE - CLINIC PF-GASTROESOPHAGEAL REFLX TEST EACH 91034 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526106 PHYSICIAN FEE - CLINIC PF-GI WIRELESS CAPSULE MEASURE EACH 91112 $263.00 960 $184.10 $131.50 $210.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563547 PHYSICIAN FEE - CLINIC PF-GLUC MONIT CONT PHYS I&R EACH 95251 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563539 PHYSICIAN FEE - CLINIC PF-GLUCOSE MONITORING CONT EACH 95250 $375.00 960 $262.50 $187.50 $300.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557606 PHYSICIAN FEE - CLINIC PF-HEMORRHOIDECTOMY SMP EACH 46221 $512.00 960 $358.40 $256.00 $409.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558174 PHYSICIAN FEE - CLINIC PF-HYMENECTOMY SINGLE INC EACH 56442 $129.00 960 $90.30 $64.50 $103.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557473 PHYSICIAN FEE - CLINIC "PF-I & D, ABSCESS, PERITON " EACH 42700 $364.00 960 $254.80 $182.00 $291.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558141 PHYSICIAN FEE - CLINIC PF-I&D ABSC GLAND BARTHOLI EACH 56420 $299.00 960 $209.30 $149.50 $239.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551427 PHYSICIAN FEE - CLINIC PF-I&D ABSC SMP EACH 10060 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563935 PHYSICIAN FEE - CLINIC PF-I&D ABSC SUBLING EXTRAOR EACH 41015 $781.00 960 $546.70 $390.50 $624.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558133 PHYSICIAN FEE - CLINIC PF-I&D ABSC VULVA/PERINEAL EACH 56405 $341.00 960 $238.70 $170.50 $272.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551450 PHYSICIAN FEE - CLINIC PF-I&D CYST PILONIDAL CPLX EACH 10081 $467.00 960 $326.90 $233.50 $373.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551443 PHYSICIAN FEE - CLINIC PF-I&D CYST PILONIDAL SMP EACH 10080 $281.00 960 $196.70 $140.50 $224.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551484 PHYSICIAN FEE - CLINIC PF-I&D HEMATOMA/SEROMA/FLU EACH 10140 $314.00 960 $219.80 $157.00 $251.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557515 PHYSICIAN FEE - CLINIC "PF-I&D, ISCHI/PERI RECTAL " EACH 45005 $458.00 960 $320.60 $229.00 $366.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525017 PHYSICIAN FEE - CLINIC PF-ICUT ALLERGY TEST DRUG/BUG EACH 95024 $4.00 960 $2.80 $2.00 $3.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526270 PHYSICIAN FEE - CLINIC PF-IMMUNOTHERAPY INJECTIONS EACH 95117 $32.00 960 $22.40 $16.00 $25.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526247 PHYSICIAN FEE - CLINIC PF-IMMUNOTHERAPY ONE INJECTION EACH 95115 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558919 PHYSICIAN FEE - CLINIC PF-IMPLANT ELECTRODE EACH 63650 "$1,098.00 " 960 $768.60 $549.00 $878.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555790 PHYSICIAN FEE - CLINIC PF-INCISION METATAR (SWANS EACH 28309 "$2,451.00 " 960 "$1,715.70 " "$1,225.50 " "$1,960.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557564 PHYSICIAN FEE - CLINIC PF-INCISION RECTAL ABSCESS EACH 46040 "$1,169.00 " 960 $818.30 $584.50 $935.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551468 PHYSICIAN FEE - CLINIC PF-INCISION/REM FB SUBQ SM EACH 10120 $278.00 960 $194.60 $139.00 $222.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525926 PHYSICIAN FEE - CLINIC PF-INGEST CHALLENGE-ADD 60 MIN EACH 95079 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525991 PHYSICIAN FEE - CLINIC PF-INGESTION CHALLENGE-120 MIN EACH 95076 $186.00 960 $130.20 $93.00 $148.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559156 PHYSICIAN FEE - CLINIC PF-INJ AA/STRD GNCLR NERVE EACH 64454 $215.00 960 $150.50 $107.50 $172.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563216 PHYSICIAN FEE - CLINIC PF-INJ CHEMONUCLEOLYSIS LUM EACH 62292 "$1,530.00 " 960 "$1,071.00 " $765.00 "$1,224.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558729 PHYSICIAN FEE - CLINIC PF-INJ EPIDURAL BLOOD/CLOT EACH 62273 $298.00 960 $208.60 $149.00 $238.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552367 PHYSICIAN FEE - CLINIC PF-INJ INTRALESNAL >7 LESN EACH 11901 $119.00 960 $83.30 $59.50 $95.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552359 PHYSICIAN FEE - CLINIC PF-INJ INTRALESNAL TO 7 LE EACH 11900 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558760 PHYSICIAN FEE - CLINIC PF-INJ MYELOGRAM/CT SPINAL EACH 62284 $218.00 960 $152.60 $109.00 $174.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558745 PHYSICIAN FEE - CLINIC PF-INJ NEUROLYTIC CERV/THO EACH 62281 $404.00 960 $282.80 $202.00 $323.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558752 PHYSICIAN FEE - CLINIC PF-INJ NEUROLYTIC LUMB/CAU EACH 62282 $370.00 960 $259.00 $185.00 $296.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563224 PHYSICIAN FEE - CLINIC PF-INJ OCCLUS ART A/V MALF EACH 62294 "$2,866.00 " 960 "$2,006.20 " "$1,433.00 " "$2,292.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563794 PHYSICIAN FEE - CLINIC PF-INJ PARAVERT W/US C/T 3 EACH 0215T $230.00 960 $161.00 $115.00 $184.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552375 PHYSICIAN FEE - CLINIC PF-INJ SQ FILL MAT UP TO 1 EACH 11950 $142.00 960 $99.40 $71.00 $113.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552383 PHYSICIAN FEE - CLINIC PF-INJ SUBQ FILL MAT 1.1-5 EACH 11951 $199.00 960 $139.30 $99.50 $159.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552391 PHYSICIAN FEE - CLINIC PF-INJ SUBQ FILL MAT>10CC EACH 11954 $305.00 960 $213.50 $152.50 $244.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562168 PHYSICIAN FEE - CLINIC PF-INJ SUBQ FILL MATER 5-10 EACH 11952 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558802 PHYSICIAN FEE - CLINIC PF-INJECTION(S) SPINE C/T EACH 62321 $281.00 960 $196.70 $140.50 $224.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557150 PHYSICIAN FEE - CLINIC PF-INS CATH CV NON-TUNL >5 EACH 36556 $225.00 960 $157.50 $112.50 $180.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557028 PHYSICIAN FEE - CLINIC PF-INSERT EMERGENCY AIRWAY EACH 31500 $381.00 960 $266.70 $190.50 $304.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557895 PHYSICIAN FEE - CLINIC PF-INSTILL ANTICARCIN BLAD EACH 51720 $116.00 960 $81.20 $58.00 $92.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98521636 PHYSICIAN FEE - CLINIC PF-INTRADERM ALLERGEN DELAY EACH 95028 $33.00 960 $23.10 $16.50 $26.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98521628 PHYSICIAN FEE - CLINIC PF-INTRADERM ALLERGEN IMMED EACH 95027 $14.00 960 $9.80 $7.00 $11.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560113 PHYSICIAN FEE - CLINIC PF-INTRAVITREAL EACH 67028 $235.00 960 $164.50 $117.50 $188.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563141 PHYSICIAN FEE - CLINIC PF-INTRO HEMOSTATIC AGNT/PK EACH 57180 $326.00 960 $228.20 $163.00 $260.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563133 PHYSICIAN FEE - CLINIC PF-IRRIG/APPL MEDICMENT VAG EACH 57150 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553852 PHYSICIAN FEE - CLINIC PF-JT INJ - MAJOR W/US EACH 20611 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559883 PHYSICIAN FEE - CLINIC PF-KERATPLASTY PENETRAT EACH 65730 "$3,198.00 " 960 "$2,238.60 " "$1,599.00 " "$2,558.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552722 PHYSICIAN FEE - CLINIC PF-LAC CPLX TRUNK 1.1-2.5C EACH 13100 $528.00 960 $369.60 $264.00 $422.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558554 PHYSICIAN FEE - CLINIC PF-LAPARO VAG HYSTERECTOMY EACH 58550 "$2,415.00 " 960 "$1,690.50 " "$1,207.50 " "$1,932.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557044 PHYSICIAN FEE - CLINIC PF-LARYNGOSCOPY INDIRECT EACH 31505 $131.00 960 $91.70 $65.50 $104.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561095 PHYSICIAN FEE - CLINIC PF-LASER TX SKIN < 250 CM EACH 96920 $160.00 960 $112.00 $80.00 $128.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561103 PHYSICIAN FEE - CLINIC PF-LASER TX SKIN 250-500 EACH 96921 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551971 PHYSICIAN FEE - CLINIC PF-LES BGN FACE/EAR TO 0.5 EACH 11440 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552029 PHYSICIAN FEE - CLINIC PF-LESN BGN FACE/EAR > 4.0 EACH 11446 $848.00 960 $593.60 $424.00 $678.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552011 PHYSICIAN FEE - CLINIC PF-LESN BGN FACE/EAR 3.1-4 EACH 11444 $601.00 960 $420.70 $300.50 $480.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551963 PHYSICIAN FEE - CLINIC PF-LESN BGN SCALP/HND >4.0 EACH 11426 $721.00 960 $504.70 $360.50 $576.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552185 PHYSICIAN FEE - CLINIC PF-LESN MAL FACE/EAR 1.1-2 EACH 11642 $481.00 960 $336.70 $240.50 $384.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557218 PHYSICIAN FEE - CLINIC "PF-LIGATION/BX, TEMPORAL A " EACH 37609 $560.00 960 $392.00 $280.00 $448.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98558000 PHYSICIAN FEE - CLINIC PF-MEATOTOMY (INFANT) EACH 53025 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563885 PHYSICIAN FEE - CLINIC PF-MEDICARE-1ST PREVENT EX EACH G0402 $338.00 960 $236.60 $169.00 $270.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553514 PHYSICIAN FEE - CLINIC PF-MOHS 1 STAGE H/N/HF/G A EACH 17312 $494.00 960 $345.80 $247.00 $395.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559875 PHYSICIAN FEE - CLINIC PF-MULT PUNC ANTERIOR CORN EACH 65600 $872.00 960 $610.40 $436.00 $697.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560964 PHYSICIAN FEE - CLINIC PF-MYRINGOT W/INFL EUST TU EACH 69420 $321.00 960 $224.70 $160.50 $256.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557267 PHYSICIAN FEE - CLINIC PF-NEEDLE BX LYMPH NODES EACH 38505 $223.00 960 $156.10 $111.50 $178.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561178 PHYSICIAN FEE - CLINIC PF-NEG PRESS WOUND TX <50 EACH 97605 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563232 PHYSICIAN FEE - CLINIC PF-NEUROLYT PUDENDAL NERVE EACH 64630 $518.00 960 $362.60 $259.00 $414.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559636 PHYSICIAN FEE - CLINIC "PF-NEUROLYTIC, CELIAC PLEX " EACH 64680 $419.00 960 $293.30 $209.50 $335.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557838 PHYSICIAN FEE - CLINIC PF-NJ URETHROCYSTOGRAM RET EACH 51610 $169.00 960 $118.30 $84.50 $135.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526312 PHYSICIAN FEE - CLINIC PF-NOSE ALLERGY TEST EACH 95065 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563554 PHYSICIAN FEE - CLINIC PF-OSTEOPATHIC MANIP 1-2 RG EACH 98925 $59.00 960 $41.30 $29.50 $47.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563562 PHYSICIAN FEE - CLINIC PF-OSTEOPATHIC MANIP 3-4 RG EACH 98926 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563570 PHYSICIAN FEE - CLINIC PF-OSTEOPATHIC MANIP 5-6 RG EACH 98927 $118.00 960 $82.60 $59.00 $94.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563588 PHYSICIAN FEE - CLINIC PF-OSTEOPATHIC MANIP 7-8 RG EACH 98928 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563596 PHYSICIAN FEE - CLINIC PF-OSTEOPATHIC MANIP 9-10 EACH 98929 $178.00 960 $124.60 $89.00 $142.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555360 PHYSICIAN FEE - CLINIC PF-PARTIAL REM TOE-PROXIML EACH 28160 $704.00 960 $492.80 $352.00 $563.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525009 PHYSICIAN FEE - CLINIC PF-PERCUT ALLERGY SKIN TESTS EACH 95004 $11.00 960 $7.70 $5.50 $8.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526239 PHYSICIAN FEE - CLINIC PF-PHOTO PATCH TEST EACH 95052 $17.00 960 $11.90 $8.50 $13.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561087 PHYSICIAN FEE - CLINIC PF-PHOTOCHEMO UVB EACH 96910 $300.00 960 $210.00 $150.00 $240.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526338 PHYSICIAN FEE - CLINIC PF-PHOTOSENSITIVITY TESTS EACH 95056 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563190 PHYSICIAN FEE - CLINIC PF-PLACE EXT VENTRIC DRAIN EACH 61107 $948.00 960 $663.60 $474.00 $758.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550965 PHYSICIAN FEE - CLINIC PF-PREVENTIVE ESTAB < 1 YR EACH 99391 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551021 PHYSICIAN FEE - CLINIC PF-PREVENTIVE ESTAB > 65 Y EACH 99397 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550999 PHYSICIAN FEE - CLINIC PF-PREVENTIVE ESTAB 12-17 EACH 99394 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550973 PHYSICIAN FEE - CLINIC PF-PREVENTIVE ESTAB 1-4 YR EACH 99392 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551005 PHYSICIAN FEE - CLINIC PF-PREVENTIVE ESTAB 18-39 EACH 99395 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551013 PHYSICIAN FEE - CLINIC PF-PREVENTIVE ESTAB 40-64 EACH 99396 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550981 PHYSICIAN FEE - CLINIC PF-PREVENTIVE ESTAB 5-11 Y EACH 99393 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550890 PHYSICIAN FEE - CLINIC PF-PREVENTIVE NEW < 1 YR EACH 99381 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550957 PHYSICIAN FEE - CLINIC PF-PREVENTIVE NEW > 65 YRS EACH 99387 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550924 PHYSICIAN FEE - CLINIC PF-PREVENTIVE NEW 12-17 YR EACH 99384 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550908 PHYSICIAN FEE - CLINIC PF-PREVENTIVE NEW 1-4 YRS EACH 99382 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550932 PHYSICIAN FEE - CLINIC PF-PREVENTIVE NEW 18-39 YR EACH 99385 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550940 PHYSICIAN FEE - CLINIC PF-PREVENTIVE NEW 40-64 YR EACH 99386 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550916 PHYSICIAN FEE - CLINIC PF-PREVENTIVE NEW 5-11 YRS EACH 99383 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98565476 PHYSICIAN FEE - CLINIC PF-PROLNG OP E/M EACH 15 MIN EACH 99417 $77.00 960 $53.90 $38.50 $61.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560196 PHYSICIAN FEE - CLINIC PF-PROPHYL RD CRYO/DIATHER EACH 67141 $554.00 960 $387.80 $277.00 $443.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560204 PHYSICIAN FEE - CLINIC PF-PROPHYL RETINAL PHOTOCO EACH 67145 $554.00 960 $387.80 $277.00 $443.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561046 PHYSICIAN FEE - CLINIC PF-PUMP MAINT SPINAL/BRAIN EACH 95990 $232.00 960 $162.40 $116.00 $185.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563125 PHYSICIAN FEE - CLINIC PF-PUNCT ASP HYDROCELE/TUNI EACH 55000 $225.00 960 $157.50 $112.50 $180.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559180 PHYSICIAN FEE - CLINIC PF-PVB THORACIC 2ND+ INJ S EACH 64462 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552318 PHYSICIAN FEE - CLINIC PF-RECONSTRUCT NAIL BED W/ EACH 11762 $493.00 960 $345.10 $246.50 $394.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525793 PHYSICIAN FEE - CLINIC PF-RECTAL SENSATION TEST EACH 91120 $122.00 960 $85.40 $61.00 $97.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555485 PHYSICIAN FEE - CLINIC PF-RELEASE EXTENSOR TENDON EACH 28225 $701.00 960 $490.70 $350.50 $560.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554942 PHYSICIAN FEE - CLINIC PF-RELEASE TARSAL TUNNEL EACH 28035 $956.00 960 $669.20 $478.00 $764.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553969 PHYSICIAN FEE - CLINIC PF-REM EXOSTOSIS MANDIBLE EACH 21031 $711.00 960 $497.70 $355.50 $568.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557317 PHYSICIAN FEE - CLINIC PF-REM FB EMBED MOUTH SIMP EACH 40804 $299.00 960 $209.30 $149.50 $239.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555402 PHYSICIAN FEE - CLINIC PF-REM FB FOOT SUBQ EACH 28190 $349.00 960 $244.30 $174.50 $279.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556798 PHYSICIAN FEE - CLINIC PF-REM/BIV FULL ARM/LEG CA EACH 29705 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555154 PHYSICIAN FEE - CLINIC PF-REM/GRAFT FT LES W/GRAF EACH 28102 "$1,685.00 " 960 "$1,179.50 " $842.50 "$1,348.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98539349 PHYSICIAN FEE - CLINIC PF-REMOTE IMAGE SUBMIT BY PT EACH G2010 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555345 PHYSICIAN FEE - CLINIC "PF-REMOVAL OF TOE, EACH TO " EACH 28150 $738.00 960 $516.60 $369.00 $590.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562903 PHYSICIAN FEE - CLINIC PF-REMOVAL SALIVARY STONE EACH 42335 $704.00 960 $492.80 $352.00 $563.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562911 PHYSICIAN FEE - CLINIC PF-REMOVAL TONSILS < 12 YRS EACH 42825 $721.00 960 $504.70 $360.50 $576.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562929 PHYSICIAN FEE - CLINIC PF-REMOVAL TONSILS > 12 YRS EACH 42826 $688.00 960 $481.60 $344.00 $550.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555097 PHYSICIAN FEE - CLINIC PF-REMOVE FOOT LESION-MORT EACH 28080 $999.00 960 $699.30 $499.50 $799.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555170 PHYSICIAN FEE - CLINIC PF-REMOVE LES TAR/MET W/GR EACH 28106 "$1,114.00 " 960 $779.80 $557.00 $891.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551724 PHYSICIAN FEE - CLINIC PF-REMOVE SKIN TAG EA ADDL EACH 11201 $43.00 960 $30.10 $21.50 $34.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551716 PHYSICIAN FEE - CLINIC PF-REMOVE SKIN TAG UP TO 1 EACH 11200 $200.00 960 $140.00 $100.00 $160.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557762 PHYSICIAN FEE - CLINIC PF-REMOVE TUNNELED IP CATH EACH 49422 $624.00 960 $436.80 $312.00 $499.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555188 PHYSICIAN FEE - CLINIC PF-REMOVE/GRAFT LES W/ALLO EACH 28107 $906.00 960 $634.20 $453.00 $724.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555436 PHYSICIAN FEE - CLINIC PF-REP/GRAFT FOOT TEND 1 EACH 28200 $868.00 960 $607.60 $434.00 $694.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555444 PHYSICIAN FEE - CLINIC PF-REP/GRAFT FOOT TEND 2 EACH 28202 "$1,131.00 " 960 $791.70 $565.50 $904.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552300 PHYSICIAN FEE - CLINIC PF-REPAIR OF NAIL BED EACH 11760 $289.00 960 $202.30 $144.50 $231.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556178 PHYSICIAN FEE - CLINIC PF-REPAIR OPEN TARSAL DISL EACH 28555 "$1,797.00 " 960 "$1,257.90 " $898.50 "$1,437.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554322 PHYSICIAN FEE - CLINIC PF-RER WRIST TENDON LESION EACH 25112 "$1,076.00 " 960 $753.20 $538.00 $860.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560527 PHYSICIAN FEE - CLINIC PF-REVISE EYLID DEFECT EACH 67911 "$1,433.00 " 960 "$1,003.10 " $716.50 "$1,146.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556384 PHYSICIAN FEE - CLINIC PF-REVISE FT BONES (MILLER EACH 28737 "$1,858.00 " 960 "$1,300.60 " $929.00 "$1,486.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555584 PHYSICIAN FEE - CLINIC PF-REVISE MIDFT EXT-CLUBFO EACH 28262 "$2,528.00 " 960 "$1,769.60 " "$1,264.00 " "$2,022.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555253 PHYSICIAN FEE - CLINIC PF-REVISION OF FOOT - TASR EACH 28116 "$1,556.00 " 960 "$1,089.20 " $778.00 "$1,244.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555576 PHYSICIAN FEE - CLINIC PF-REVISION OF MIDFOOT TEN EACH 28261 "$2,282.00 " 960 "$1,597.40 " "$1,141.00 " "$1,825.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555816 PHYSICIAN FEE - CLINIC PF-REVISION OF TOE NOT BIG EACH 28312 $922.00 960 $645.40 $461.00 $737.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563711 PHYSICIAN FEE - CLINIC PF-RISK REDUCT GROUP 30MIN EACH 99411 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563729 PHYSICIAN FEE - CLINIC PF-RISK REDUCT GROUP 60MIN EACH 99412 $33.00 960 $23.10 $16.50 $26.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563653 PHYSICIAN FEE - CLINIC PF-RISK REDUCT INDIV 15 MIN EACH 99401 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563661 PHYSICIAN FEE - CLINIC PF-RISK REDUCT INDIV 30 MIN EACH 99402 $123.00 960 $86.10 $61.50 $98.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563679 PHYSICIAN FEE - CLINIC PF-RISK REDUCT INDIV 45 MIN EACH 99403 $183.00 960 $128.10 $91.50 $146.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563687 PHYSICIAN FEE - CLINIC PF-RISK REDUCT INDIV 60 MIN EACH 99404 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563950 PHYSICIAN FEE - CLINIC PF-RME-INIT SET-UP & EDUC EACH 99453 $0.00 960 $0.00 $0.00 $0.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559776 PHYSICIAN FEE - CLINIC PF-RPR LAC CONJUNCT EACH 65272 $902.00 960 $631.40 $451.00 $721.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559768 PHYSICIAN FEE - CLINIC PF-RPR LAC CONJUNCT CL DIR EACH 65270 $359.00 960 $251.30 $179.50 $287.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559792 PHYSICIAN FEE - CLINIC PF-RPR LAC CORNEA W/GLUE EACH 65286 "$1,266.00 " 960 $886.20 $633.00 "$1,012.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552763 PHYSICIAN FEE - CLINIC PF-RPR LAC CPL SCLP 2.6-7. EACH 13121 $677.00 960 $473.90 $338.50 $541.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552813 PHYSICIAN FEE - CLINIC PF-RPR LAC CPLX EYE 1.1-2. EACH 13151 $732.00 960 $512.40 $366.00 $585.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552821 PHYSICIAN FEE - CLINIC PF-RPR LAC CPLX EYE 2.6-7. EACH 13152 $883.00 960 $618.10 $441.50 $706.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552789 PHYSICIAN FEE - CLINIC PF-RPR LAC CPLX FHD 1.1-2. EACH 13131 $637.00 960 $445.90 $318.50 $509.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552797 PHYSICIAN FEE - CLINIC PF-RPR LAC CPLX FRD 2.6-7. EACH 13132 $793.00 960 $555.10 $396.50 $634.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552748 PHYSICIAN FEE - CLINIC PF-RPR LAC CPLX TK EA AD 5 EACH 13102 $194.00 960 $135.80 $97.00 $155.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552730 PHYSICIAN FEE - CLINIC PF-RPR LAC CPLX TRK 2.6-7. EACH 13101 $646.00 960 $452.20 $323.00 $516.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552649 PHYSICIAN FEE - CLINIC PF-RPR LAC INT NECK 2.6-7. EACH 12042 $514.00 960 $359.80 $257.00 $411.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552631 PHYSICIAN FEE - CLINIC PF-RPR LAC INT NECK TO 2.5 EACH 12041 $383.00 960 $268.10 $191.50 $306.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552623 PHYSICIAN FEE - CLINIC PF-RPR LAC INT S/A 7.6-12. EACH 12034 $544.00 960 $380.80 $272.00 $435.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552516 PHYSICIAN FEE - CLINIC PF-RPR LAC SMP FACE TO 2.5 EACH 12011 $155.00 960 $108.50 $77.50 $124.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552482 PHYSICIAN FEE - CLINIC PF-RPR S/N/A/GEN/TRK12.6-2 EACH 12005 $267.00 960 $186.90 $133.50 $213.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552490 PHYSICIAN FEE - CLINIC PF-RPR S/N/A/GEN/TRK20.1-3 EACH 12006 $325.00 960 $227.50 $162.50 $260.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552474 PHYSICIAN FEE - CLINIC PF-RPR S/N/AX/GEN/TRK7.6-1 EACH 12004 $206.00 960 $144.20 $103.00 $164.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552508 PHYSICIAN FEE - CLINIC PF-RPR S/N/AX/GEN/TRNK >30 EACH 12007 $404.00 960 $282.80 $202.00 $323.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562861 PHYSICIAN FEE - CLINIC PF-SCLERO SOLN VEIN LIMB/TR EACH 36468 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525272 PHYSICIAN FEE - CLINIC PF-SCRN VISUAL ACUITY BI EACH 99173 $10.00 960 $7.00 $5.00 $8.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551765 PHYSICIAN FEE - CLINIC PF-SHAVE SKIN LESION >2.0 EACH 11303 $187.00 960 $130.90 $93.50 $149.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551807 PHYSICIAN FEE - CLINIC PF-SHV LESN SKN SCALP >2.0 EACH 11308 $183.00 960 $128.10 $91.50 $146.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551781 PHYSICIAN FEE - CLINIC PF-SHV LESN SKN SCALP.6-1. EACH 11306 $128.00 960 $89.60 $64.00 $102.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557531 PHYSICIAN FEE - CLINIC PF-SIGMOIDOSCOPY W/BX EACH 45331 $191.00 960 $133.70 $95.50 $152.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552862 PHYSICIAN FEE - CLINIC PF-SKIN TISSUE REARRANGE T EACH 14001 "$1,770.00 " 960 "$1,239.00 " $885.00 "$1,416.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562200 PHYSICIAN FEE - CLINIC PF-SKN SUB GRF T/A/L CHILD+ EACH 15274 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563703 PHYSICIAN FEE - CLINIC PF-SMOK CESS INTEN >10 MN EACH 99407 $65.00 960 $45.50 $32.50 $52.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563695 PHYSICIAN FEE - CLINIC PF-SMOK CESS INTER >3MIN EACH 99406 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561053 PHYSICIAN FEE - CLINIC PF-SPINE/BRAIN PUMP REFILL EACH 95991 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563059 PHYSICIAN FEE - CLINIC PF-STIMULUS EVOKED RESPONSE EACH 51792 $148.00 960 $103.60 $74.00 $118.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556756 PHYSICIAN FEE - CLINIC PF-STRAP UNNA BOOT EACH 29580 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562762 PHYSICIAN FEE - CLINIC PF-STRAPPING ELBOW OR WRIST EACH 29260 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562770 PHYSICIAN FEE - CLINIC PF-STRAPPING OF HIP EACH 29520 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562788 PHYSICIAN FEE - CLINIC PF-STRAPPING OF KNEE EACH 29530 $46.00 960 $32.20 $23.00 $36.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562754 PHYSICIAN FEE - CLINIC PF-STRAPPING THORAX EACH 29200 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557937 PHYSICIAN FEE - CLINIC PF-STUDY VP INTRA-ABDOMINA EACH 51797 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553217 PHYSICIAN FEE - CLINIC PF-SUCT LIPECTOMY HEAD&NEC EACH 15876 "$1,227.00 " 960 $858.90 $613.50 $981.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555089 PHYSICIAN FEE - CLINIC PF-SYNOVECTOMY METATAR JT EACH 28072 $865.00 960 $605.50 $432.50 $692.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551658 PHYSICIAN FEE - CLINIC PF-TANGENTIAL SKIN BIOPSY EACH 11102 $99.00 960 $69.30 $49.50 $79.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562143 PHYSICIAN FEE - CLINIC PF-TATTOO MICROPIG 6.1-20. EACH 11921 $354.00 960 $247.80 $177.00 $283.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562150 PHYSICIAN FEE - CLINIC PF-TATTOO MICROPIGMENT +20 EACH 11922 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562135 PHYSICIAN FEE - CLINIC PF-TATTOO MICROPIGMENT <6.0 EACH 11920 $308.00 960 $215.60 $154.00 $246.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552912 PHYSICIAN FEE - CLINIC PF-TIS TRNFR E/N/E/L10.1-3 EACH 14061 "$2,157.00 " 960 "$1,509.90 " "$1,078.50 " "$1,725.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552854 PHYSICIAN FEE - CLINIC PF-TIS TRNFR TRUNK 10 SQ C EACH 14000 "$1,358.00 " 960 $950.60 $679.00 "$1,086.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552870 PHYSICIAN FEE - CLINIC PF-TIS XFER S/A/L 10 CM< EACH 14020 "$1,505.00 " 960 "$1,053.50 " $752.50 "$1,204.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98539430 PHYSICIAN FEE - CLINIC PF-TONGUE & MOUTH SURGERY EACH 41599 "$1,196.00 " 960 $837.20 $598.00 $956.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559917 PHYSICIAN FEE - CLINIC PF-TRABECULOPLASTY LASER EACH 65855 $526.00 960 $368.20 $263.00 $420.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563737 PHYSICIAN FEE - CLINIC PF-TRANS CARE MGT 14 DAY EACH 99495 $360.00 960 $252.00 $180.00 $288.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563745 PHYSICIAN FEE - CLINIC PF-TRANS CARE MGT 7 DAY EACH 99496 $488.00 960 $341.60 $244.00 $390.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554876 PHYSICIAN FEE - CLINIC PF-TREAT FOOT BONE LESION EACH 28005 "$1,505.00 " 960 "$1,053.50 " $752.50 "$1,204.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554868 PHYSICIAN FEE - CLINIC PF-TREAT FOOT INFECTION EACH 28003 $686.00 960 $480.20 $343.00 $548.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552227 PHYSICIAN FEE - CLINIC PF-TRIM NAILS NONDYSTROPHI EACH 11719 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554363 PHYSICIAN FEE - CLINIC PF-TRT FX RADIUS/ULNA W/O EACH 25600 $893.00 960 $625.10 $446.50 $714.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98553233 PHYSICIAN FEE - CLINIC PF-TX BURN 1ST DEGREE INIT EACH 16000 $125.00 960 $87.50 $62.50 $100.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556194 PHYSICIAN FEE - CLINIC PF-TX CL FT DISLOCAT W/ANE EACH 28575 $937.00 960 $655.90 $468.50 $749.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562655 PHYSICIAN FEE - CLINIC PF-TX CLOSD TARSO JT W/O AN EACH 28600 $425.00 960 $297.50 $212.50 $340.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562614 PHYSICIAN FEE - CLINIC PF-TX CLOSED ANKLE FRACT EACH 28430 $575.00 960 $402.50 $287.50 $460.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556038 PHYSICIAN FEE - CLINIC PF-TX CLOSED METATARSAL FR EACH 28475 $620.00 960 $434.00 $310.00 $496.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556103 PHYSICIAN FEE - CLINIC PF-TX CLOSED TOE FRACT W/M EACH 28515 $385.00 960 $269.50 $192.50 $308.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556095 PHYSICIAN FEE - CLINIC PF-TX CLOSED TOE FRACT WO EACH 28510 $324.00 960 $226.80 $162.00 $259.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554512 PHYSICIAN FEE - CLINIC PF-TX DISLOC HAND W/MAN EA EACH 26670 $879.00 960 $615.30 $439.50 $703.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554611 PHYSICIAN FEE - CLINIC PF-TX DISLOC KNEECAP W/O A EACH 27560 $953.00 960 $667.10 $476.50 $762.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562580 PHYSICIAN FEE - CLINIC PF-TX DISTAL FIBULAR FX EACH 27792 "$1,764.00 " 960 "$1,234.80 " $882.00 "$1,411.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554793 PHYSICIAN FEE - CLINIC PF-TX FX ANKLE BIMALLEOLR EACH 27808 $844.00 960 $590.80 $422.00 $675.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554785 PHYSICIAN FEE - CLINIC PF-TX FX ANKLE DISTAL FIB EACH 27786 $792.00 960 $554.40 $396.00 $633.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554777 PHYSICIAN FEE - CLINIC PF-TX FX ANKLE FIBULA W/O EACH 27780 $788.00 960 $551.60 $394.00 $630.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554769 PHYSICIAN FEE - CLINIC PF-TX FX ANKLE MEDIAL W/O EACH 27760 $848.00 960 $593.60 $424.00 $678.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554496 PHYSICIAN FEE - CLINIC PF-TX FX METACARP 1 W/MANI EACH 26600 $793.00 960 $555.10 $396.50 $634.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562630 PHYSICIAN FEE - CLINIC PF-TX FX METATARSAL W/O MAN EACH 28470 $556.00 960 $389.20 $278.00 $444.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554330 PHYSICIAN FEE - CLINIC PF-TX FX RAD AND ULNA EACH 25520 "$1,511.00 " 960 "$1,057.70 " $755.50 "$1,208.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554355 PHYSICIAN FEE - CLINIC PF-TX FX RAD/ULNA W/O MANI EACH 25560 $721.00 960 $504.70 $360.50 $576.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98554348 PHYSICIAN FEE - CLINIC PF-TX FX ULNA W/O MANIP EACH 25530 $673.00 960 $471.10 $336.50 $538.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555923 PHYSICIAN FEE - CLINIC PF-TX HEEL FRACT CLOSED W/ EACH 28405 "$1,126.00 " 960 $788.20 $563.00 $900.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555931 PHYSICIAN FEE - CLINIC PF-TX HEEL FRACT PERCUT W/ EACH 28406 "$1,615.00 " 960 "$1,130.50 " $807.50 "$1,292.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556004 PHYSICIAN FEE - CLINIC PF-TX MIDFOOT FRACT W/MAP EACH 28455 $604.00 960 $422.80 $302.00 $483.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562598 PHYSICIAN FEE - CLINIC PF-TX OPEN ANKLE FRACT EACH 27814 "$2,095.00 " 960 "$1,466.50 " "$1,047.50 " "$1,676.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98555980 PHYSICIAN FEE - CLINIC PF-TX OPEN ANKLE FRACTURE EACH 28445 "$2,855.00 " 960 "$1,998.50 " "$1,427.50 " "$2,284.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556087 PHYSICIAN FEE - CLINIC PF-TX OPEN BIG TOE FRACTUR EACH 28505 "$1,326.00 " 960 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556020 PHYSICIAN FEE - CLINIC PF-TX OPEN MIDFOOT FRACT E EACH 28465 "$1,726.00 " 960 "$1,208.20 " $863.00 "$1,380.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556111 PHYSICIAN FEE - CLINIC PF-TX OPEN TOE FRACTURE EACH 28525 "$1,087.00 " 960 $760.90 $543.50 $869.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556319 PHYSICIAN FEE - CLINIC PF-TX PERC INTRPHLNGL DISL EACH 28666 $458.00 960 $320.60 $229.00 $366.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556277 PHYSICIAN FEE - CLINIC PF-TX PERC METATPHALN DISL EACH 28636 $612.00 960 $428.40 $306.00 $489.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556012 PHYSICIAN FEE - CLINIC PF-TX PERC MIDFT FRACT W/O EACH 28456 $999.00 960 $699.30 $499.50 $799.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556202 PHYSICIAN FEE - CLINIC PF-TX PERC TALOTARSAL DISL EACH 28576 "$1,073.00 " 960 $751.10 $536.50 $858.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556236 PHYSICIAN FEE - CLINIC PF-TX PERC TARSMETAT DISLO EACH 28606 "$1,071.00 " 960 $749.70 $535.50 $856.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556079 PHYSICIAN FEE - CLINIC PF-TX PERCUT BIG TOE FRACT EACH 28496 $744.00 960 $520.80 $372.00 $595.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556046 PHYSICIAN FEE - CLINIC PF-TX PERCUT METATARSAL FR EACH 28476 "$1,033.00 " 960 $723.10 $516.50 $826.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561137 PHYSICIAN FEE - CLINIC PF-ULTRAVIOLET THERAPY EACH 97028 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98556855 PHYSICIAN FEE - CLINIC PF-UNLISTED CASTING/STRAPP EACH 29799 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98533870 PHYSICIAN FEE - CLINIC PF-US URINE CAPACITY MEASURE EACH 51798 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562846 PHYSICIAN FEE - CLINIC PF-VEIN ACCESS CUTDOWN<1 EACH 36420 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562853 PHYSICIAN FEE - CLINIC PF-VEIN ACCESS CUTDOWN>1 YR EACH 36425 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98562382 PHYSICIAN FEE - CLINIC PF-VERTEBROPLASTY ADDL INJ EACH 22512 $567.00 960 $396.90 $283.50 $453.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550841 PHYSICIAN FEE - CLINIC PF-VISIT OP ESTAB LEVEL 1 EACH 99211 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550858 PHYSICIAN FEE - CLINIC PF-VISIT OP ESTAB LEVEL 2 EACH 99212 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550866 PHYSICIAN FEE - CLINIC PF-VISIT OP ESTAB LEVEL 3 EACH 99213 $171.00 960 $119.70 $85.50 $136.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550874 PHYSICIAN FEE - CLINIC PF-VISIT OP ESTAB LEVEL 4 EACH 99214 $251.00 960 $175.70 $125.50 $200.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550882 PHYSICIAN FEE - CLINIC PF-VISIT OP ESTAB LEVEL 5 EACH 99215 $374.00 960 $261.80 $187.00 $299.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550791 PHYSICIAN FEE - CLINIC PF-VISIT OP NEW LEVEL 1 EACH 99201 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550809 PHYSICIAN FEE - CLINIC PF-VISIT OP NEW LEVEL 2 EACH 99202 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550817 PHYSICIAN FEE - CLINIC PF-VISIT OP NEW LEVEL 3 EACH 99203 $216.00 960 $151.20 $108.00 $172.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550825 PHYSICIAN FEE - CLINIC PF-VISIT OP NEW LEVEL 4 EACH 99204 $349.00 960 $244.30 $174.50 $279.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98550833 PHYSICIAN FEE - CLINIC PF-VISIT OP NEW LEVEL 5 EACH 99205 $475.00 960 $332.50 $237.50 $380.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98560139 PHYSICIAN FEE - CLINIC "PF-VITRECTOMY, MECHANICAL " EACH 67040 "$2,645.00 " 960 "$1,851.50 " "$1,322.50 " "$2,116.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561079 PHYSICIAN FEE - CLINIC PF-WHOLE BODY PHOTOGRAPHY EACH 96904 $174.00 960 $121.80 $87.00 $139.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561202 PHYSICIAN FEE - CLINIC PF-WOUND VAC >50 CM EACH 97608 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98552904 PHYSICIAN FEE - CLINIC PF-XFER TISS EYE/EAR/LP <1 EACH 14060 "$1,752.00 " 960 "$1,226.40 " $876.00 "$1,401.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500673 PHYSICIAN FEE - CT PF-CARD MRI VELOC FLOW MAPPING EACH 75565 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500681 PHYSICIAN FEE - CT PF-CORON ARTERY W/CALC SCORING EACH 75571 $70.00 960 $49.00 $35.00 $56.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500749 PHYSICIAN FEE - CT PF-CT 3D RENDERING W/O PROCESS EACH 76376 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500657 PHYSICIAN FEE - CT PF-CT ABD & PELVIS W/ CONTRAST EACH 74177 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500632 PHYSICIAN FEE - CT PF-CT ABD & PELVIS W/O CONT EACH 74176 $210.00 960 $147.00 $105.00 $168.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500665 PHYSICIAN FEE - CT PF-CT ABD&PELVIS 1+ SECT/REGNS EACH 74178 $241.00 960 $168.70 $120.50 $192.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500616 PHYSICIAN FEE - CT PF-CT ABDOMEN W&W/O CONTRAST EACH 74170 $168.00 960 $117.60 $84.00 $134.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500608 PHYSICIAN FEE - CT PF-CT ABDOMEN W/CONTRAST EACH 74160 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500590 PHYSICIAN FEE - CT PF-CT ABDOMEN W/O CONTRAST EACH 74150 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500731 PHYSICIAN FEE - CT PF-CT ANGIO ABDOMINAL ARTERIES EACH 75635 $286.00 960 $200.20 $143.00 $228.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500723 PHYSICIAN FEE - CT PF-CT ANGIO HRT W/3D IMAGE EACH 75574 $286.00 960 $200.20 $143.00 $228.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500772 PHYSICIAN FEE - CT PF-CT BONE MINERAL DENS AXIAL EACH 77078 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500244 PHYSICIAN FEE - CT PF-CT CERV SPINE W/CONTRAST EACH 72126 $147.00 960 $102.90 $73.50 $117.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500236 PHYSICIAN FEE - CT PF-CT CERV SPINE W/O CONTRAST EACH 72125 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500251 PHYSICIAN FEE - CT PF-CT CERVICAL SPINE W&WO CONT EACH 72127 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500756 PHYSICIAN FEE - CT PF-CT FOLLOW UP/LIMITED STUDY EACH 76380 $116.00 960 $81.20 $58.00 $92.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500061 PHYSICIAN FEE - CT PF-CT FOS/SEL/EAR W&W/O CONT EACH 70482 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500053 PHYSICIAN FEE - CT PF-CT FOS/SEL/EAR W/CONTRAST EACH 70481 $137.00 960 $95.90 $68.50 $109.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500046 PHYSICIAN FEE - CT PF-CT FOS/SEL/EAR W/O CONTRAST EACH 70480 $156.00 960 $109.20 $78.00 $124.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500764 PHYSICIAN FEE - CT PF-CT GUIDE LOCALIZTION STEREO EACH 77011 $158.00 960 $110.60 $79.00 $126.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500038 PHYSICIAN FEE - CT PF-CT HEAD/BRAIN W&W/O CONT EACH 70470 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500020 PHYSICIAN FEE - CT PF-CT HEAD/BRAIN W/CONTRAST EACH 70460 $137.00 960 $95.90 $68.50 $109.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500004 PHYSICIAN FEE - CT PF-CT HEAD/BRAIN W/O CONTRAST EACH 70450 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500699 PHYSICIAN FEE - CT PF-CT HRT W/3D IMAGE EACH 75572 $208.00 960 $145.60 $104.00 $166.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500707 PHYSICIAN FEE - CT PF-CT HRT W/3D IMAGE CONGEN EACH 75573 $304.00 960 $212.80 $152.00 $243.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500327 PHYSICIAN FEE - CT PF-CT LUMBAR SP W&WO CONTRAST EACH 72133 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500319 PHYSICIAN FEE - CT PF-CT LUMBAR SPINE W/CONTRAST EACH 72132 $147.00 960 $102.90 $73.50 $117.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500301 PHYSICIAN FEE - CT PF-CT LUMBAR SPINE W/O CONT EACH 72131 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500525 PHYSICIAN FEE - CT PF-CT LWR EXT W&W/O CONT BI EACH 73702 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500533 PHYSICIAN FEE - CT PF-CT LWR EXT W&W/O CONT LT EACH 73702 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500517 PHYSICIAN FEE - CT PF-CT LWR EXT W&W/O CONT RT EACH 73702 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500491 PHYSICIAN FEE - CT PF-CT LWR EXT W/CONTRAST BI EACH 73701 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500475 PHYSICIAN FEE - CT PF-CT LWR EXT W/CONTRAST LT EACH 73701 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500483 PHYSICIAN FEE - CT PF-CT LWR EXT W/CONTRAST RT EACH 73701 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500467 PHYSICIAN FEE - CT PF-CT LWR EXT W/O CONTRAST BI EACH 73700 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500459 PHYSICIAN FEE - CT PF-CT LWR EXT W/O CONTRAST LT EACH 73700 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500442 PHYSICIAN FEE - CT PF-CT LWR EXT W/O CONTRAST RT EACH 73700 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500111 PHYSICIAN FEE - CT PF-CT MAX/FACIAL W&W/O CONT EACH 70488 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500103 PHYSICIAN FEE - CT PF-CT MAX/FACIAL W/CONTRAST EACH 70487 $136.00 960 $95.20 $68.00 $108.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500095 PHYSICIAN FEE - CT PF-CT MAX/FACIAL W/O CONTRAST EACH 70486 $103.00 960 $72.10 $51.50 $82.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500145 PHYSICIAN FEE - CT PF-CT NECK W&W/O CONTRAST EACH 70492 $194.00 960 $135.80 $97.00 $155.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500137 PHYSICIAN FEE - CT PF-CT NECK W/CONTRAST EACH 70491 $167.00 960 $116.90 $83.50 $133.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500129 PHYSICIAN FEE - CT PF-CT NECK W/O CONTRAST EACH 70490 $155.00 960 $108.50 $77.50 $124.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500376 PHYSICIAN FEE - CT PF-CT PELVIS W&W/O CONTRAST EACH 72194 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500350 PHYSICIAN FEE - CT PF-CT PELVIS W/CONTRAST EACH 72193 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500343 PHYSICIAN FEE - CT PF-CT PELVIS W/O CONTRAST EACH 72192 $132.00 960 $92.40 $66.00 $105.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500285 PHYSICIAN FEE - CT PF-CT THORACIC SP W&WO CONT EACH 72130 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500277 PHYSICIAN FEE - CT PF-CT THORACIC SPINE W/CONT EACH 72129 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500269 PHYSICIAN FEE - CT PF-CT THORACIC SPINE WO CONT EACH 72128 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500202 PHYSICIAN FEE - CT PF-CT THORAX W&W/O CONTRAST EACH 71270 $150.00 960 $105.00 $75.00 $120.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500194 PHYSICIAN FEE - CT PF-CT THORAX W/CONTRAST EACH 71260 $141.00 960 $98.70 $70.50 $112.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500186 PHYSICIAN FEE - CT PF-CT THORAX W/O CONTRAST EACH 71250 $131.00 960 $91.70 $65.50 $104.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500806 PHYSICIAN FEE - CT PF-CT UPR EXT W/CONTRAST BILAT EACH 73201 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500814 PHYSICIAN FEE - CT PF-CT UPR EXT W/CONTRAST LT EACH 73201 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500822 PHYSICIAN FEE - CT PF-CT UPR EXT W/CONTRAST RT EACH 73201 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500400 PHYSICIAN FEE - CT PF-CT UPR EXT W/O CONTRAST BI EACH 73200 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500392 PHYSICIAN FEE - CT PF-CT UPR EXT W/O CONTRAST LT EACH 73200 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500384 PHYSICIAN FEE - CT PF-CT UPR EXT W/O CONTRAST RT EACH 73200 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500624 PHYSICIAN FEE - CT PF-CTA ABDOMEN W/CONTRAST EACH 74175 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500210 PHYSICIAN FEE - CT PF-CTA CHST W& IF DONE W/O CON EACH 71275 $220.00 960 $154.00 $110.00 $176.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500160 PHYSICIAN FEE - CT PF-CTA HEAD& IF DONE POST PROC EACH 70496 $211.00 960 $147.70 $105.50 $168.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500558 PHYSICIAN FEE - CT PF-CTA LWR EXT W/&WO CONT RT EACH 73706 $227.00 960 $158.90 $113.50 $181.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500566 PHYSICIAN FEE - CT PF-CTA LWR EXT W/CONTRAST BI EACH 73706 $227.00 960 $158.90 $113.50 $181.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500541 PHYSICIAN FEE - CT PF-CTA LWR EXT W/CONTRAST LT EACH 73706 $227.00 960 $158.90 $113.50 $181.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500178 PHYSICIAN FEE - CT PF-CTA NECK W& IF WO & POST EACH 70498 $211.00 960 $147.70 $105.50 $168.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500335 PHYSICIAN FEE - CT PF-CTA PELVIS W& IF WO CON EACH 72191 $216.00 960 $151.20 $108.00 $172.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500418 PHYSICIAN FEE - CT PF-CTA UPR EXT W& IF WO CON LT EACH 73206 $216.00 960 $151.20 $108.00 $172.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500426 PHYSICIAN FEE - CT PF-CTA UPR EXT W& IF WO CON RT EACH 73206 $216.00 960 $151.20 $108.00 $172.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500798 PHYSICIAN FEE - CT PF-LDCT LUNG CANCER SCREENING EACH 71271 $131.00 960 $91.70 $65.50 $104.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96500798 PHYSICIAN FEE - CT PF-LDCT LUNG CANCER SCREENING EACH G0297 $131.00 960 $91.70 $65.50 $104.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300022 PHYSICIAN FEE - DIALYSIS PF-DIAB MANAGE TRN IND/GROUP EACH G0109 $40.00 960 $28.00 $20.00 $32.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300071 PHYSICIAN FEE - DIALYSIS PF-DIAB MANAGE TRN PER INDIV EACH G0108 $139.00 960 $97.30 $69.50 $111.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300105 PHYSICIAN FEE - DIALYSIS PF-DIALYSIS ONE EVALUATION EACH 90945 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300147 PHYSICIAN FEE - DIALYSIS PF-DIALYSIS REPEATED EVAL EACH 90947 $315.00 960 $220.50 $157.50 $252.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300063 PHYSICIAN FEE - DIALYSIS PF-ED SVC CKD GRP PER SESSION EACH G0421 $70.00 960 $49.00 $35.00 $56.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300139 PHYSICIAN FEE - DIALYSIS PF-ED SVC CKD IND PER SESSION EACH G0420 $280.00 960 $196.00 $140.00 $224.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300303 PHYSICIAN FEE - DIALYSIS PF-ESRD HOME PT SERV MO <2YRS EACH 90963 "$1,555.00 " 960 "$1,088.50 " $777.50 "$1,244.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300253 PHYSICIAN FEE - DIALYSIS PF-ESRD HOME PT SERV MO 12-19 EACH 90965 "$1,278.00 " 960 $894.60 $639.00 "$1,022.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300055 PHYSICIAN FEE - DIALYSIS PF-ESRD HOME PT SERV P DAY <2 EACH 90967 $45.00 960 $31.50 $22.50 $36.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300170 PHYSICIAN FEE - DIALYSIS PF-ESRD HOME PT SERV P MO 20+ EACH 90966 $751.00 960 $525.70 $375.50 $600.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300287 PHYSICIAN FEE - DIALYSIS PF-ESRD HOME PT SERV P MO 2-11 EACH 90964 "$1,333.00 " 960 $933.10 $666.50 "$1,066.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300030 PHYSICIAN FEE - DIALYSIS PF-ESRD HOME PT SRV DAY 12-19 EACH 90969 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300048 PHYSICIAN FEE - DIALYSIS PF-ESRD HOME PT SRV P DAY 2-11 EACH 90968 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300162 PHYSICIAN FEE - DIALYSIS PF-ESRD SERV 1 VISIT P MO 20+ EACH 90962 $518.00 960 $362.60 $259.00 $414.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300204 PHYSICIAN FEE - DIALYSIS PF-ESRD SERV 1 VST P MO 12-19 EACH 90959 $836.00 960 $585.20 $418.00 $668.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300329 PHYSICIAN FEE - DIALYSIS PF-ESRD SERV 4 VSTS P MO 2-11 EACH 90954 "$2,577.00 " 960 "$1,803.90 " "$1,288.50 " "$2,061.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300238 PHYSICIAN FEE - DIALYSIS PF-ESRD SRV 1 VISIT P MO <2YRS EACH 90953 "$1,000.00 " 960 $700.00 $500.00 $800.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300212 PHYSICIAN FEE - DIALYSIS PF-ESRD SRV 1 VISIT P MO 2-11 EACH 90956 $889.00 960 $622.30 $444.50 $711.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300246 PHYSICIAN FEE - DIALYSIS PF-ESRD SRV 2-3 VSTS MO 12-19 EACH 90958 "$1,281.00 " 960 $896.70 $640.50 "$1,024.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300279 PHYSICIAN FEE - DIALYSIS PF-ESRD SRV 2-3 VSTS P MO <2YR EACH 90952 "$2,196.00 " 960 "$1,537.20 " "$1,098.00 " "$1,756.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300188 PHYSICIAN FEE - DIALYSIS PF-ESRD SRV 2-3 VSTS P MO 20+ EACH 90961 $751.00 960 $525.70 $375.50 $600.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300261 PHYSICIAN FEE - DIALYSIS PF-ESRD SRV 2-3 VSTS P MO 2-11 EACH 90955 "$1,340.00 " 960 $938.00 $670.00 "$1,072.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300337 PHYSICIAN FEE - DIALYSIS PF-ESRD SRV 4 VISITS P MO <2YR EACH 90951 "$3,012.00 " 960 "$2,108.40 " "$1,506.00 " "$2,409.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300196 PHYSICIAN FEE - DIALYSIS PF-ESRD SRV 4 VISITS P MO 20+ EACH 90960 $904.00 960 $632.80 $452.00 $723.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300311 PHYSICIAN FEE - DIALYSIS PF-ESRD SRV 4 VSTS P MO 12-19 EACH 90957 "$1,970.00 " 960 "$1,379.00 " $985.00 "$1,576.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300097 PHYSICIAN FEE - DIALYSIS PF-HEMODIALYSIS ONE EVALUATION EACH 90935 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300121 PHYSICIAN FEE - DIALYSIS PF-HEMODIALYSIS REPEATED EVAL EACH 90937 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99300113 PHYSICIAN FEE - DIALYSIS PF-HEMOPERFUSION EACH 90997 $225.00 960 $157.50 $112.50 $180.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500100 PHYSICIAN FEE - DUPLEX PF-DOPPLER ART EXT W/STRESS EACH 93924 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500068 PHYSICIAN FEE - DUPLEX PF-DOPPLER ARTERIAL EXT CMPL EACH 93923 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500274 PHYSICIAN FEE - DUPLEX PF-DOPPLER INTRACRAN EMB W/INJ EACH 93893 $153.00 960 $107.10 $76.50 $122.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500266 PHYSICIAN FEE - DUPLEX PF-DOPPLER INTRACRAN EMBOL W/O EACH 93892 $150.00 960 $105.00 $75.00 $120.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500258 PHYSICIAN FEE - DUPLEX PF-DOPPLER INTRACRAN VASOREACT EACH 93890 $129.00 960 $90.30 $64.50 $103.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500241 PHYSICIAN FEE - DUPLEX PF-DOPPLER TRANSCRANIAL CMPL EACH 93886 $117.00 960 $81.90 $58.50 $93.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500126 PHYSICIAN FEE - DUPLEX PF-DOPPLER TRANSCRANIAL LTD EACH 93888 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500290 PHYSICIAN FEE - DUPLEX PF-DUPLEX ABD/PEL/RETRO CMPL EACH 93975 $142.00 960 $99.40 $71.00 $113.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500225 PHYSICIAN FEE - DUPLEX PF-DUPLEX ABD/PEL/RETRO LTD EACH 93976 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500183 PHYSICIAN FEE - DUPLEX PF-DUPLEX AORTA/IVC/GRAFT CMPL EACH 93978 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500134 PHYSICIAN FEE - DUPLEX PF-DUPLEX AORTA/IVC/GRAFT LTD EACH 93979 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500167 PHYSICIAN FEE - DUPLEX PF-DUPLEX ART LWR EXT UNI/LMTD EACH 93926 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500159 PHYSICIAN FEE - DUPLEX PF-DUPLEX ART UPR EXT UNI/LMTD EACH 93931 $62.00 960 $43.40 $31.00 $49.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500233 PHYSICIAN FEE - DUPLEX PF-DUPLEX ARTERIAL LWR EXT BI EACH 93925 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500209 PHYSICIAN FEE - DUPLEX PF-DUPLEX ARTERIAL UPR EXT BI EACH 93930 $100.00 960 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500191 PHYSICIAN FEE - DUPLEX PF-DUPLEX EXTRACRANIAL BILAT EACH 93880 $99.00 960 $69.30 $49.50 $79.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500118 PHYSICIAN FEE - DUPLEX PF-DUPLEX EXTRACRANIAL UNILAT EACH 93882 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500092 PHYSICIAN FEE - DUPLEX PF-DUPLEX HEMODIALYSIS ACCESS EACH 93990 $64.00 960 $44.80 $32.00 $51.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500308 PHYSICIAN FEE - DUPLEX PF-DUPLEX PENILE VESSELS CMPL EACH 93980 $148.00 960 $103.60 $74.00 $118.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500050 PHYSICIAN FEE - DUPLEX PF-DUPLEX PENILE VESSELS LTD EACH 93981 $54.00 960 $37.80 $27.00 $43.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500175 PHYSICIAN FEE - DUPLEX PF-DUPLEX VENOUS EXT BILAT EACH 93970 $86.00 960 $60.20 $43.00 $68.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500084 PHYSICIAN FEE - DUPLEX PF-DUPLEX VENOUS EXT UNIL/LMTD EACH 93971 $54.00 960 $37.80 $27.00 $43.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100045 PHYSICIAN FEE - DX RADIOLOGY PF-ADD XR MANDIBLE <4V LT EACH 70100 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102736 PHYSICIAN FEE - DX RADIOLOGY PF-CINE/VIDEO X-RAYS ADD-ON EACH 76125 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102447 PHYSICIAN FEE - DX RADIOLOGY PF-CONTRAST X-RAY EXAM COLON EACH 74283 $253.00 960 $177.10 $126.50 $202.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102454 PHYSICIAN FEE - DX RADIOLOGY PF-CONTRAST X-RAY GALLBLADDER EACH 74290 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102249 PHYSICIAN FEE - DX RADIOLOGY PF-CONTRST X-RAY EXAM THROAT EACH 74210 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102538 PHYSICIAN FEE - DX RADIOLOGY PF-CONTRST X-RAY URINARY TRACT EACH 74410 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102231 PHYSICIAN FEE - DX RADIOLOGY PF-CT ANGIO ABD&PELV W/O&W/DYE EACH 74174 $264.00 960 $184.80 $132.00 $211.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102397 PHYSICIAN FEE - DX RADIOLOGY PF-CT COLONOGRAPHY DX EACH 74261 $269.00 960 $188.30 $134.50 $215.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102405 PHYSICIAN FEE - DX RADIOLOGY PF-CT COLONOGRAPHY DX W/DYE EACH 74262 $302.00 960 $211.40 $151.00 $241.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102793 PHYSICIAN FEE - DX RADIOLOGY PF-ECHO EXAM OF EYE EACH 76529 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102785 PHYSICIAN FEE - DX RADIOLOGY PF-ECHO EXAM OF EYE WATER BATH EACH 76513 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102850 PHYSICIAN FEE - DX RADIOLOGY PF-ECHO GUIDANCE RADIOTHERAPY EACH 76965 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103007 PHYSICIAN FEE - DX RADIOLOGY PF-ECHO GUIDANCE RADIOTHERAPY EACH G6001 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102819 PHYSICIAN FEE - DX RADIOLOGY PF-ECHO GUIDE ARTERY REPAIR EACH 76936 $246.00 960 $172.20 $123.00 $196.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102801 PHYSICIAN FEE - DX RADIOLOGY PF-ECHO GUIDE FOR HEART BIOPSY EACH 76932 $96.00 960 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102827 PHYSICIAN FEE - DX RADIOLOGY PF-ECHO GUIDE FOR TRANSFUSION EACH 76941 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102843 PHYSICIAN FEE - DX RADIOLOGY PF-ECHO GUIDE OVA ASPIRATION EACH 76948 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102884 PHYSICIAN FEE - DX RADIOLOGY PF-FLUORO GUIDE SPINE INJECT EACH 77003 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100359 PHYSICIAN FEE - DX RADIOLOGY PF-FULL MOUTH X-RAY OF TEETH EACH 70320 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102967 PHYSICIAN FEE - DX RADIOLOGY PF-JOINT SURVEY SINGLE VIEW EACH 77077 $43.00 960 $30.10 $21.50 $34.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102611 PHYSICIAN FEE - DX RADIOLOGY PF-LYMPH VESSEL X-RAY ARM/LEG EACH 75801 $116.00 960 $81.20 $58.00 $92.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102637 PHYSICIAN FEE - DX RADIOLOGY PF-LYMPH VESSEL XRAY ARMS/LEGS EACH 75803 $142.00 960 $99.40 $71.00 $113.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102777 PHYSICIAN FEE - DX RADIOLOGY PF-OPHTH US QUANT A ONLY EACH 76511 $57.00 960 $39.90 $28.50 $45.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102751 PHYSICIAN FEE - DX RADIOLOGY PF-RADIOGRAPHIC PROCEDURE EACH 76499 $199.99 960 $139.99 $100.00 $159.99 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103023 PHYSICIAN FEE - DX RADIOLOGY PF-SET UP PORT XRAY EQUIPMENT EACH Q0092 $67.00 960 $46.90 $33.50 $53.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102991 PHYSICIAN FEE - DX RADIOLOGY PF-SINGLE ENERGY X-RAY STUDY EACH G0130 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103015 PHYSICIAN FEE - DX RADIOLOGY PF-STEREOSCOPIC X-RAY GUIDANCE EACH G6002 $53.00 960 $37.10 $26.50 $42.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100425 PHYSICIAN FEE - DX RADIOLOGY PF-THROAT X-RAY & FLUOROSCOPY EACH 70370 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103056 PHYSICIAN FEE - DX RADIOLOGY PF-TRANSPORT PORT X-RAY MULTI EACH R0075 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103031 PHYSICIAN FEE - DX RADIOLOGY PF-TRANSPORT PORTABLE X-RAY EACH R0070 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101118 PHYSICIAN FEE - DX RADIOLOGY PF-XR AC JOINT W/O WTS UNI LT EACH 73050 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101100 PHYSICIAN FEE - DX RADIOLOGY PF-XR AC JOINT W/O WTS UNI RT EACH 73050 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101092 PHYSICIAN FEE - DX RADIOLOGY PF-XR AC JOINTS BILAT W/O WTS EACH 73050 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101985 PHYSICIAN FEE - DX RADIOLOGY PF-XR ANKLE 1V BILAT EACH 73600 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102009 PHYSICIAN FEE - DX RADIOLOGY PF-XR ANKLE 1V LT EACH 73600 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101977 PHYSICIAN FEE - DX RADIOLOGY PF-XR ANKLE 1V RT EACH 73600 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101969 PHYSICIAN FEE - DX RADIOLOGY PF-XR ANKLE 2V BILAT EACH 73600 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101951 PHYSICIAN FEE - DX RADIOLOGY PF-XR ANKLE 2V LT EACH 73600 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101944 PHYSICIAN FEE - DX RADIOLOGY PF-XR ANKLE 2V RT EACH 73600 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102033 PHYSICIAN FEE - DX RADIOLOGY PF-XR ANKLE 3+V BIL EACH 73610 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102025 PHYSICIAN FEE - DX RADIOLOGY PF-XR ANKLE 3+V LT EACH 73610 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102017 PHYSICIAN FEE - DX RADIOLOGY PF-XR ANKLE 3+V RT EACH 73610 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102918 PHYSICIAN FEE - DX RADIOLOGY PF-XR BONE AGE STUDIES EACH 77072 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102926 PHYSICIAN FEE - DX RADIOLOGY PF-XR BONE LENGTH STUDIES EACH 77073 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102942 PHYSICIAN FEE - DX RADIOLOGY PF-XR BONE SURVEY COMPLETE EACH 77075 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102959 PHYSICIAN FEE - DX RADIOLOGY PF-XR BONE SURVEY INFANT EACH 77076 $86.00 960 $60.20 $43.00 $68.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102934 PHYSICIAN FEE - DX RADIOLOGY PF-XR BONE SURVEY LIMITED EACH 77074 $53.00 960 $37.10 $26.50 $42.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102140 PHYSICIAN FEE - DX RADIOLOGY PF-XR CALCANEUS 2+V BIL EACH 73650 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102124 PHYSICIAN FEE - DX RADIOLOGY PF-XR CALCANEUS 2+V LT EACH 73650 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102116 PHYSICIAN FEE - DX RADIOLOGY PF-XR CALCANEUS 2+V RT EACH 73650 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100722 PHYSICIAN FEE - DX RADIOLOGY PF-XR CERV SPINE COMP W/OBL/F EACH 72052 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102462 PHYSICIAN FEE - DX RADIOLOGY PF-XR CHOLANGIOGRAM OR EACH 74300 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100979 PHYSICIAN FEE - DX RADIOLOGY PF-XR CLAVICLE CMPL BIL EACH 73000 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100953 PHYSICIAN FEE - DX RADIOLOGY PF-XR CLAVICLE CMPL LT EACH 73000 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100961 PHYSICIAN FEE - DX RADIOLOGY PF-XR CLAVICLE CMPL RT EACH 73000 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100912 PHYSICIAN FEE - DX RADIOLOGY PF-XR COCCYX EACH 72220 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102421 PHYSICIAN FEE - DX RADIOLOGY PF-XR COLON ENEMA BARIUM EACH 74270 $125.00 960 $87.50 $62.50 $100.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100706 PHYSICIAN FEE - DX RADIOLOGY PF-XR C-SPINE 2-3V EACH 72040 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101241 PHYSICIAN FEE - DX RADIOLOGY PF-XR ELBOW 2V BIL EACH 73070 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101258 PHYSICIAN FEE - DX RADIOLOGY PF-XR ELBOW 2V LT EACH 73070 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101233 PHYSICIAN FEE - DX RADIOLOGY PF-XR ELBOW 2V RT EACH 73070 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101282 PHYSICIAN FEE - DX RADIOLOGY PF-XR ELBOW CMPL 3+V BIL EACH 73080 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101274 PHYSICIAN FEE - DX RADIOLOGY PF-XR ELBOW CMPL 3+V LT EACH 73080 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101266 PHYSICIAN FEE - DX RADIOLOGY PF-XR ELBOW CMPL 3+V RT EACH 73080 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102439 PHYSICIAN FEE - DX RADIOLOGY PF-XR ENEMA BARIUM W/AIR EACH 74280 $153.00 960 $107.10 $76.50 $122.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102256 PHYSICIAN FEE - DX RADIOLOGY PF-XR ESOPHAGUS EACH 74220 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100003 PHYSICIAN FEE - DX RADIOLOGY PF-XR EYE FOREIGN BODY EACH 70030 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100193 PHYSICIAN FEE - DX RADIOLOGY PF-XR FACIAL BONES < 3 V BIL EACH 70140 $25.00 960 $17.50 $12.50 $20.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100185 PHYSICIAN FEE - DX RADIOLOGY PF-XR FACIAL BONES < 3 V LT EACH 70140 $25.00 960 $17.50 $12.50 $20.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100169 PHYSICIAN FEE - DX RADIOLOGY PF-XR FACIAL BONES < 3 V RT EACH 70140 $25.00 960 $17.50 $12.50 $20.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100201 PHYSICIAN FEE - DX RADIOLOGY PF-XR FACIAL BONES 3+V EACH 70150 $32.00 960 $22.40 $16.00 $25.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101704 PHYSICIAN FEE - DX RADIOLOGY PF-XR FEMUR 2V BIL EACH 73552 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101688 PHYSICIAN FEE - DX RADIOLOGY PF-XR FEMUR 2V LT EACH 73552 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101696 PHYSICIAN FEE - DX RADIOLOGY PF-XR FEMUR 2V RT EACH 73552 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101563 PHYSICIAN FEE - DX RADIOLOGY PF-XR FINGER(S) 2+V BIL EACH 73140 $18.00 960 $12.60 $9.00 $14.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101548 PHYSICIAN FEE - DX RADIOLOGY PF-XR FINGER(S) 2+V LT EACH 73140 $18.00 960 $12.60 $9.00 $14.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101555 PHYSICIAN FEE - DX RADIOLOGY PF-XR FINGER(S) 2+V RT EACH 73140 $18.00 960 $12.60 $9.00 $14.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102660 PHYSICIAN FEE - DX RADIOLOGY PF-XR FLUORO <1HR EACH 76000 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102868 PHYSICIAN FEE - DX RADIOLOGY PF-XR FLUORO CV ACCESS PLACEMT EACH 77001 $48.00 960 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102876 PHYSICIAN FEE - DX RADIOLOGY PF-XR FLUORO NEEDLE PLACEMENT EACH 77002 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102074 PHYSICIAN FEE - DX RADIOLOGY PF-XR FOOT 2V BILAT EACH 73620 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102058 PHYSICIAN FEE - DX RADIOLOGY PF-XR FOOT 2V LT EACH 73620 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102041 PHYSICIAN FEE - DX RADIOLOGY PF-XR FOOT 2V RT EACH 73620 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102108 PHYSICIAN FEE - DX RADIOLOGY PF-XR FOOT CMPL 3+V BILAT EACH 73630 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102082 PHYSICIAN FEE - DX RADIOLOGY PF-XR FOOT CMPL 3+V LT EACH 73630 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102090 PHYSICIAN FEE - DX RADIOLOGY PF-XR FOOT CMPL 3+V RT EACH 73630 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101324 PHYSICIAN FEE - DX RADIOLOGY PF-XR FOREARM 2V BIL EACH 73090 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101308 PHYSICIAN FEE - DX RADIOLOGY PF-XR FOREARM 2V LT EACH 73090 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101316 PHYSICIAN FEE - DX RADIOLOGY PF-XR FOREARM 2V RT EACH 73090 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101472 PHYSICIAN FEE - DX RADIOLOGY PF-XR HAND 2 VIEWS BIL EACH 73120 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101498 PHYSICIAN FEE - DX RADIOLOGY PF-XR HAND 2 VIEWS LT EACH 73120 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101480 PHYSICIAN FEE - DX RADIOLOGY PF-XR HAND 2 VIEWS RT EACH 73120 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101530 PHYSICIAN FEE - DX RADIOLOGY PF-XR HAND CMPL 3+V BIL EACH 73130 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101522 PHYSICIAN FEE - DX RADIOLOGY PF-XR HAND CMPL 3+V LT EACH 73130 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101514 PHYSICIAN FEE - DX RADIOLOGY PF-XR HAND CMPL 3+V RT EACH 73130 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101589 PHYSICIAN FEE - DX RADIOLOGY PF-XR HIP 1 VIEW BIL EACH 73501 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101613 PHYSICIAN FEE - DX RADIOLOGY PF-XR HIP CMPL 2+V LT EACH 73502 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101662 PHYSICIAN FEE - DX RADIOLOGY PF-XR HIPS BI 2V EA HIP W/PELV EACH 73522 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101142 PHYSICIAN FEE - DX RADIOLOGY PF-XR HUMERUS 2+V BIL EACH 73060 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101191 PHYSICIAN FEE - DX RADIOLOGY PF-XR HUMERUS 2+V LT EACH 73060 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101126 PHYSICIAN FEE - DX RADIOLOGY PF-XR HUMERUS 2+V RT EACH 73060 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101720 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE 1-2V BILAT EACH 73560 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101738 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE 1-2V LT EACH 73560 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101746 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE 1-2V RT EACH 73560 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101753 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE 3 VIEWS LT EACH 73562 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101761 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE 3 VIEWS RT EACH 73562 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101779 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE 3V BILAT EACH 73562 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101829 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE AP STANDING BILAT EACH 73565 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101837 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE AP STANDING LT EACH 73565 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101845 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE AP STANDING RT EACH 73565 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101795 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE CMPL 4+V BIL EACH 73564 $29.00 960 $20.30 $14.50 $23.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101811 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE CMPL 4+V LT EACH 73564 $29.00 960 $20.30 $14.50 $23.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101803 PHYSICIAN FEE - DX RADIOLOGY PF-XR KNEE CMPL 4+V RT EACH 73564 $29.00 960 $20.30 $14.50 $23.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100821 PHYSICIAN FEE - DX RADIOLOGY PF-XR L-SPINE 4+V EACH 72110 $32.00 960 $22.40 $16.00 $25.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100847 PHYSICIAN FEE - DX RADIOLOGY PF-XR L-SPINE BENDING MIN 4V EACH 72120 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100839 PHYSICIAN FEE - DX RADIOLOGY PF-XR LUMB COMP W/BENDING V EACH 72114 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100813 PHYSICIAN FEE - DX RADIOLOGY PF-XR LUMBAR SPINE 2 OR 3 V EACH 72100 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101910 PHYSICIAN FEE - DX RADIOLOGY PF-XR LWR EXT INFANT 2+V BI EACH 73592 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101936 PHYSICIAN FEE - DX RADIOLOGY PF-XR LWR EXT INFANT 2+V LT EACH 73592 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101902 PHYSICIAN FEE - DX RADIOLOGY PF-XR LWR EXT INFANT 2+V RT EACH 73592 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100029 PHYSICIAN FEE - DX RADIOLOGY PF-XR MANDIBLE <4V BIL EACH 70100 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100011 PHYSICIAN FEE - DX RADIOLOGY PF-XR MANDIBLE <4V RT EACH 70100 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100060 PHYSICIAN FEE - DX RADIOLOGY PF-XR MANDIBLE CMPL 4+V BIL EACH 70110 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100078 PHYSICIAN FEE - DX RADIOLOGY PF-XR MANDIBLE CMPL 4+V LT EACH 70110 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100052 PHYSICIAN FEE - DX RADIOLOGY PF-XR MANDIBLE CMPL 4+V RT EACH 70110 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100110 PHYSICIAN FEE - DX RADIOLOGY PF-XR MASTOIDS <3V BIL EACH 70120 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100094 PHYSICIAN FEE - DX RADIOLOGY PF-XR MASTOIDS <3V LT EACH 70120 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100086 PHYSICIAN FEE - DX RADIOLOGY PF-XR MASTOIDS <3V RT EACH 70120 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100144 PHYSICIAN FEE - DX RADIOLOGY PF-XR MASTOIDS CMPL 3+V BILAT EACH 70130 $42.00 960 $29.40 $21.00 $33.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100136 PHYSICIAN FEE - DX RADIOLOGY PF-XR MASTOIDS CMPL 3+V LT EACH 70130 $42.00 960 $29.40 $21.00 $33.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100128 PHYSICIAN FEE - DX RADIOLOGY PF-XR MASTOIDS CMPL 3+V RT EACH 70130 $42.00 960 $29.40 $21.00 $33.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100219 PHYSICIAN FEE - DX RADIOLOGY PF-XR NASAL CMPL 3+V EACH 70160 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100250 PHYSICIAN FEE - DX RADIOLOGY PF-XR ORBITS CMPL 4+V BIL EACH 70200 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100268 PHYSICIAN FEE - DX RADIOLOGY PF-XR ORBITS CMPL 4+V LT EACH 70200 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100235 PHYSICIAN FEE - DX RADIOLOGY PF-XR ORBITS CMPL 4+V RT EACH 70200 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100409 PHYSICIAN FEE - DX RADIOLOGY PF-XR ORTHOPANTOGRAM EACH 70355 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100854 PHYSICIAN FEE - DX RADIOLOGY PF-XR PELVIS 1-2V EACH 72170 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100862 PHYSICIAN FEE - DX RADIOLOGY PF-XR PELVIS COMPLETE 3+ VIEWS EACH 72190 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102280 PHYSICIAN FEE - DX RADIOLOGY PF-XR REMOVE FB ESOPHAGUS S&I EACH 74235 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100607 PHYSICIAN FEE - DX RADIOLOGY PF-XR RIBS 2V UNI LT EACH 71100 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100581 PHYSICIAN FEE - DX RADIOLOGY PF-XR RIBS 2V UNI RT EACH 71100 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100631 PHYSICIAN FEE - DX RADIOLOGY PF-XR RIBS BILATERAL 3 VIEWS EACH 71110 $35.00 960 $24.50 $17.50 $28.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100623 PHYSICIAN FEE - DX RADIOLOGY PF-XR RIBS W/CXR 3+V UNI LT EACH 71101 $33.00 960 $23.10 $16.50 $26.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100615 PHYSICIAN FEE - DX RADIOLOGY PF-XR RIBS W/CXR 3+V UNI RT EACH 71101 $33.00 960 $23.10 $16.50 $26.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100888 PHYSICIAN FEE - DX RADIOLOGY PF-XR SACROILIAC JOINTS < 3 V EACH 72200 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100896 PHYSICIAN FEE - DX RADIOLOGY PF-XR SACROILIAC JOINTS 3+ V EACH 72202 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100466 PHYSICIAN FEE - DX RADIOLOGY PF-XR SALIVARY GLAND BIL EACH 70380 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100474 PHYSICIAN FEE - DX RADIOLOGY PF-XR SALIVARY GLAND LT EACH 70380 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100441 PHYSICIAN FEE - DX RADIOLOGY PF-XR SALIVARY GLAND RT EACH 70380 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101001 PHYSICIAN FEE - DX RADIOLOGY PF-XR SCAPULA CMPL BIL EACH 73010 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100995 PHYSICIAN FEE - DX RADIOLOGY PF-XR SCAPULA CMPL LT EACH 73010 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100987 PHYSICIAN FEE - DX RADIOLOGY PF-XR SCAPULA CMPL RT EACH 73010 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100292 PHYSICIAN FEE - DX RADIOLOGY PF-XR SELLA TURCICA EACH 70240 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101035 PHYSICIAN FEE - DX RADIOLOGY PF-XR SHOULDER 1 VIEW LT EACH 73020 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101027 PHYSICIAN FEE - DX RADIOLOGY PF-XR SHOULDER 1 VIEW RT EACH 73020 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101076 PHYSICIAN FEE - DX RADIOLOGY PF-XR SHOULDER CMPL 2+V BIL EACH 73030 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101050 PHYSICIAN FEE - DX RADIOLOGY PF-XR SHOULDER CMPL 2+V RT EACH 73030 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101043 PHYSICIAN FEE - DX RADIOLOGY PF-XR SHOULDER LTD 1VEW BIL EACH 73020 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100276 PHYSICIAN FEE - DX RADIOLOGY PF-XR SINUSES <3V EACH 70210 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100326 PHYSICIAN FEE - DX RADIOLOGY PF-XR SKULL CMPLL 4+V EACH 70260 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100300 PHYSICIAN FEE - DX RADIOLOGY PF-XR SKULL LTD <4V EACH 70250 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102363 PHYSICIAN FEE - DX RADIOLOGY PF-XR SMALL INTESTINE EACH 74250 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100698 PHYSICIAN FEE - DX RADIOLOGY PF-XR SPINE 1 VIEW ANY LEVEL EACH 72020 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100672 PHYSICIAN FEE - DX RADIOLOGY PF-XR STERNOCLAV JNT(S) 3+ V EACH 71130 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100656 PHYSICIAN FEE - DX RADIOLOGY PF-XR STERNUM 2+ VIEWS EACH 71120 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103064 PHYSICIAN FEE - DX RADIOLOGY PF-XR SURGICAL SPECIMEN EACH 76098 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102264 PHYSICIAN FEE - DX RADIOLOGY PF-XR SWALLOW CINE/VIDEO EACH 74230 $65.00 960 $45.50 $32.50 $52.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100748 PHYSICIAN FEE - DX RADIOLOGY PF-XR THORACIC SPINE 2 VIEWS EACH 72070 $25.00 960 $17.50 $12.50 $20.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100763 PHYSICIAN FEE - DX RADIOLOGY PF-XR THORACIC SPINE 4+ VIEWS EACH 72074 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100771 PHYSICIAN FEE - DX RADIOLOGY PF-XR THORACOLUMBAR SPINE 2 V EACH 72080 $26.00 960 $18.20 $13.00 $20.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101894 PHYSICIAN FEE - DX RADIOLOGY PF-XR TIBIA/FIBULA 2V BIL EACH 73590 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101860 PHYSICIAN FEE - DX RADIOLOGY PF-XR TIBIA/FIBULA 2V LT EACH 73590 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101878 PHYSICIAN FEE - DX RADIOLOGY PF-XR TIBIA/FIBULA 2V RT EACH 73590 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100789 PHYSICIAN FEE - DX RADIOLOGY PF-XR T-L-SPINE SCOLIOS STAND EACH 72082 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100375 PHYSICIAN FEE - DX RADIOLOGY PF-XR TMJ OPEN & CLSD BILAT EACH 70330 $29.00 960 $20.30 $14.50 $23.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102173 PHYSICIAN FEE - DX RADIOLOGY PF-XR TOE(S) 2+V BIL EACH 73660 $17.00 960 $11.90 $8.50 $13.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102165 PHYSICIAN FEE - DX RADIOLOGY PF-XR TOE(S) 2+V LT EACH 73660 $17.00 960 $11.90 $8.50 $13.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102157 PHYSICIAN FEE - DX RADIOLOGY PF-XR TOE(S) 2+V RT EACH 73660 $17.00 960 $11.90 $8.50 $13.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102702 PHYSICIAN FEE - DX RADIOLOGY PF-XR TOMOGRAM SINGLE PLANE EACH 76100 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100755 PHYSICIAN FEE - DX RADIOLOGY PF-XR T-SPINE 3V EACH 72072 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102355 PHYSICIAN FEE - DX RADIOLOGY PF-XR UGI W/AIR W/SMALL BOWEL EACH 74246 $109.00 960 $76.30 $54.50 $87.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101340 PHYSICIAN FEE - DX RADIOLOGY PF-XR UPR EXT INFANT 2+V BIL EACH 73092 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101332 PHYSICIAN FEE - DX RADIOLOGY PF-XR UPR EXT INFANT 2+V LT EACH 73092 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101357 PHYSICIAN FEE - DX RADIOLOGY PF-XR UPR EXT INFANT 2+V RT EACH 73092 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102520 PHYSICIAN FEE - DX RADIOLOGY PF-XR UROGRAM (IVP) EACH 74400 $60.00 960 $42.00 $30.00 $48.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102561 PHYSICIAN FEE - DX RADIOLOGY PF-XR UROGRAM RETROGRADE EACH 74420 $62.00 960 $43.40 $31.00 $49.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102546 PHYSICIAN FEE - DX RADIOLOGY PF-XR UROGRAM W/NEPHROTOMOGRAM EACH 74415 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101423 PHYSICIAN FEE - DX RADIOLOGY PF-XR WRIST 2V BI EACH 73100 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101373 PHYSICIAN FEE - DX RADIOLOGY PF-XR WRIST 2V LT EACH 73100 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101381 PHYSICIAN FEE - DX RADIOLOGY PF-XR WRIST 2V RT EACH 73100 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101464 PHYSICIAN FEE - DX RADIOLOGY PF-XR WRIST CMPL 3+V BI EACH 73110 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101456 PHYSICIAN FEE - DX RADIOLOGY PF-XR WRIST CMPL 3+V LT EACH 73110 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96101449 PHYSICIAN FEE - DX RADIOLOGY PF-XR WRIST CMPL 3+V RT EACH 73110 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103155 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM ABDOMEN 1 VIEW EACH 74018 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103163 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM ABDOMEN 2 VIEWS EACH 74019 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103171 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM ABDOMEN 3+ VIEWS EACH 74021 $33.00 960 $23.10 $16.50 $26.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103106 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM CHEST 1 VIEW EACH 71045 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103122 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM CHEST 2 VIEWS EACH 71046 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103130 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM CHEST 3 VIEWS EACH 71047 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96103148 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM CHEST 4+ VIEWS EACH 71048 $37.00 960 $25.90 $18.50 $29.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100227 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM OF EYE SOCKETS EACH 70190 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100367 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM OF JAW JOINT EACH 70328 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100151 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM OF MIDDLE EAR EACH 70134 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100284 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM OF SINUSES EACH 70220 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102371 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM OF SMALL BOWEL EACH 74251 $141.00 960 $98.70 $70.50 $112.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102223 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY EXAM SERIES ABDOMEN EACH 74022 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100391 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY HEAD FOR ORTHODONTIA EACH 70350 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102579 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY MALE GENITAL TRACT EACH 74440 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100714 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY NECK SPINE 4/5VWS EACH 72050 $33.00 960 $23.10 $16.50 $26.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102686 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY NOSE TO RECTUM EACH 76010 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100649 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY RIBS/CHEST4/> VWS EACH 71111 $40.00 960 $28.00 $20.00 $32.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102892 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY STRESS VIEW EACH 77071 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100342 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY TEETH PARTIAL EACH 70310 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100334 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY TEETH SINGLE VIEW EACH 70300 $14.00 960 $9.80 $7.00 $11.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102298 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAY UPPER GI DELAY WO KUB EACH 74240 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96102470 PHYSICIAN FEE - DX RADIOLOGY PF-X-RAYS AT SURGERY ADD-ON EACH 74301 $25.00 960 $17.50 $12.50 $20.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200073 PHYSICIAN FEE - EEG PF-EEG AWAKE/ASLEEP EACH 95819 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200065 PHYSICIAN FEE - EEG PF-EEG AWAKE/DROWSY EACH 95816 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200222 PHYSICIAN FEE - EEG PF-EEG CEREBRAL DEATH EVAL EACH 95824 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200081 PHYSICIAN FEE - EEG PF-EEG COMA OR SLEEP ONLY EACH 95822 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200297 PHYSICIAN FEE - EEG PF-EEG CONT REC W/VID EEG TECH EACH 95700 $597.00 960 $417.90 $298.50 $477.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200156 PHYSICIAN FEE - EEG PF-EEG CORTICAL MAP 1ST HR EACH 95961 $421.00 960 $294.70 $210.50 $336.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200172 PHYSICIAN FEE - EEG PF-EEG CORTICAL MAP ADD HR EACH 95962 $277.00 960 $193.90 $138.50 $221.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200131 PHYSICIAN FEE - EEG PF-EEG DIGITAL ANALYSIS EACH 95957 $255.00 960 $178.50 $127.50 $204.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200107 PHYSICIAN FEE - EEG PF-EEG INSERTION SPHENOIDALS EACH 95830 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200016 PHYSICIAN FEE - EEG PF-EEG INTRAOP IN OR 1 HR EACH 95941 $107.00 960 $74.90 $53.50 $85.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200008 PHYSICIAN FEE - EEG PF-EEG INTRAOP OUT OR 15MIN EACH 95940 $83.00 960 $58.10 $41.50 $66.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200115 PHYSICIAN FEE - EEG 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$266.00 $425.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200529 PHYSICIAN FEE - EEG PF-EEG PHY/QHP>60<84 HR W/VEEG EACH 95724 $809.00 960 $566.30 $404.50 $647.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200511 PHYSICIAN FEE - EEG PF-EEG PHY/QHP>60<84 HR WO VID EACH 95723 $643.00 960 $450.10 $321.50 $514.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200537 PHYSICIAN FEE - EEG PF-EEG PHY/QHP>84 HR W/O VID EACH 95725 $744.00 960 $520.80 $372.00 $595.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200552 PHYSICIAN FEE - EEG PF-EEG PHY/QHP>84 HR W/VEEG EACH 95726 "$1,038.00 " 960 $726.60 $519.00 $830.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200453 PHYSICIAN FEE - EEG PF-EEG PHYS/QHP 2-12 HR W/VEEG EACH 95718 $347.00 960 $242.90 $173.50 $277.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200446 PHYSICIAN FEE - EEG PF-EEG PHYS/QHP 2-12 HR WO VID EACH 95717 $273.00 960 $191.10 $136.50 $218.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200461 PHYSICIAN FEE - EEG PF-EEG PHYS/QHP EA INCR WO VID EACH 95719 $413.00 960 $289.10 $206.50 $330.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200305 PHYSICIAN FEE - EEG PF-EEG W/O VID 2-12 HR UNMNTR EACH 95705 $312.00 960 $218.40 $156.00 $249.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200321 PHYSICIAN FEE - EEG PF-EEG W/O VID 2-12HR CONT MNT EACH 95707 "$1,202.00 " 960 $841.40 $601.00 $961.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200362 PHYSICIAN FEE - EEG PF-EEG W/O VID EA 12-26HR CONT EACH 95710 "$2,251.00 " 960 "$1,575.70 " "$1,125.50 " "$1,800.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200354 PHYSICIAN FEE - EEG PF-EEG W/O VID EA 12-26HR INTM EACH 95709 "$1,799.00 " 960 "$1,259.30 " $899.50 "$1,439.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200149 PHYSICIAN FEE - EEG PF-EEG W/PHARM ACTIVATION EACH 95954 $283.00 960 $198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200206 PHYSICIAN FEE - EEG PF-EEG WADA TEST EACH 95958 $561.00 960 $392.70 $280.50 $448.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200313 PHYSICIAN FEE - EEG PF-EEG WO VID 2-12HR INTMT MNT EACH 95706 $951.00 960 $665.70 $475.50 $760.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200347 PHYSICIAN FEE - EEG PF-EEG WO VID EA 12-26HR UNMNT EACH 95708 $460.00 960 $322.00 $230.00 $368.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200248 PHYSICIAN FEE - EEG PF-MEG EVOKED FIELDS EA ADD EACH 95967 $438.00 960 $306.60 $219.00 $350.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200255 PHYSICIAN FEE - EEG PF-MEG EVOKED FIELDS SINGLE EACH 95966 $504.00 960 $352.80 $252.00 $403.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200289 PHYSICIAN FEE - EEG PF-MEG SPONTANEOUS ACTIVITY EACH 95965 "$1,029.00 " 960 $720.30 $514.50 $823.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200214 PHYSICIAN FEE - EEG PF-SURGERY ELECTROCORTICOGRAM EACH 95829 $831.00 960 $581.70 $415.50 $664.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200396 PHYSICIAN FEE - EEG PF-VEEG 2-12 HR CONT MNTR EACH 95713 "$1,627.00 " 960 "$1,138.90 " $813.50 "$1,301.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200388 PHYSICIAN FEE - EEG PF-VEEG 2-12 HR INTMT MNTR EACH 95712 "$1,199.00 " 960 $839.30 $599.50 $959.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200370 PHYSICIAN FEE - EEG PF-VEEG 2-12 HR UNMONITORED EACH 95711 $403.00 960 $282.10 $201.50 $322.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200412 PHYSICIAN FEE - EEG PF-VEEG EA 12-26 HR UNMNTR EACH 95714 $590.00 960 $413.00 $295.00 $472.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200438 PHYSICIAN FEE - EEG PF-VEEG EA 12-26HR CONT MNTR EACH 95716 "$2,892.00 " 960 "$2,024.40 " "$1,446.00 " "$2,313.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99200420 PHYSICIAN FEE - EEG PF-VEEG EA 12-26HR INTMT MNTR EACH 95715 "$2,139.00 " 960 "$1,497.30 " "$1,069.50 " "$1,711.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100067 PHYSICIAN FEE - EKG PF-ECG MON/REP 48HRS W/CONNECT EACH 93227 $46.00 960 $32.20 $23.00 $36.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100083 PHYSICIAN FEE - EKG PF-ECG MONIT/REPT UP TO 48 HRS EACH 93224 $183.00 960 $128.10 $91.50 $146.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100109 PHYSICIAN FEE - EKG PF-ECG RECORD/REVIEW EACH 93268 $443.00 960 $310.10 $221.50 $354.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100059 PHYSICIAN FEE - EKG PF-ECG/REVIEW INTERPRET ONLY EACH 93272 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100117 PHYSICIAN FEE - EKG PF-EKG 12 LEAD TRACING EACH 93010 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100042 PHYSICIAN FEE - EKG PF-ELECTROCARDIOGRAM COMPLETE EACH 93000 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100125 PHYSICIAN FEE - EKG PF-EVENT RECORD/DISCON 24H/30D EACH 93270 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100158 PHYSICIAN FEE - EKG PF-EVENT TRANSMIT/ANL 24H/30D EACH 93271 $361.00 960 $252.70 $180.50 $288.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100216 PHYSICIAN FEE - EKG PF-EXT ECG COMPLETE EACH 0295T $652.00 960 $456.40 $326.00 $521.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100190 PHYSICIAN FEE - EKG PF-EXT ECG RECORDING EACH 0296T $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100182 PHYSICIAN FEE - EKG PF-EXT ECG REVIEW AND INTERP EACH 0298T $652.00 960 $456.40 $326.00 $521.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99100208 PHYSICIAN FEE - EKG 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$198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98400005 PHYSICIAN FEE - EMERGENCY DEPT PF-ER LEVEL 1 EACH 99281 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98400013 PHYSICIAN FEE - EMERGENCY DEPT PF-ER LEVEL 2 EACH 99282 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98400021 PHYSICIAN FEE - EMERGENCY DEPT PF-ER LEVEL 3 EACH 99283 $189.00 960 $132.30 $94.50 $151.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98400039 PHYSICIAN FEE - EMERGENCY DEPT PF-ER LEVEL 4 EACH 99284 $321.00 960 $224.70 $160.50 $256.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98400047 PHYSICIAN FEE - EMERGENCY DEPT PF-ER LEVEL 5 EACH 99285 $465.00 960 $325.50 $232.50 $372.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400368 PHYSICIAN FEE - EMG PF-ANS PARASYMP & SYMP W/TILT EACH 95924 $168.00 960 $117.60 $84.00 $134.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400202 PHYSICIAN FEE - EMG PF-AUTONOMIC FUNC CARDIOVAGAL EACH 95921 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400210 PHYSICIAN FEE - EMG PF-AUTONOMIC FUNCTION SUDOMOTR EACH 95923 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400228 PHYSICIAN FEE - EMG PF-AUTONOMIC FUNCTION VASOMOTR EACH 95922 $115.00 960 $80.50 $57.50 $92.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400137 PHYSICIAN FEE - EMG PF-BLINK REFLEX TEST EACH 95933 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400566 PHYSICIAN FEE - EMG PF-CHEM/DEST NRV 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Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400806 PHYSICIAN FEE - EMG PF-CMPL RPR F/C/C/M/N/AX/G/H/F EACH 13133 $333.00 960 $233.10 $166.50 $266.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400087 PHYSICIAN FEE - EMG PF-DYNAMIC SURFACE EMG EACH 96002 $55.00 960 $38.50 $27.50 $44.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400509 PHYSICIAN FEE - EMG PF-ELECTRO-UROFLOWMETRY FIRST EACH 51784 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400384 PHYSICIAN FEE - EMG PF-EMG 3 EXTREMITIES EACH 95863 $247.00 960 $172.90 $123.50 $197.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400277 PHYSICIAN FEE - EMG PF-EMG CRANIAL NERVE BILAT EACH 95868 $156.00 960 $109.20 $78.00 $124.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400160 PHYSICIAN FEE - EMG PF-EMG CRANIAL NERVE UNILAT EACH 95867 $105.00 960 $73.50 $52.50 $84.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400020 PHYSICIAN FEE - EMG PF-EMG DYNAMC FINE WIRE 1 MUSC EACH 96003 $42.00 960 $29.40 $21.00 $33.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400400 PHYSICIAN FEE - EMG PF-EMG FOUR EXTREMITIES EACH 95864 $264.00 960 $184.80 $132.00 $211.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400293 PHYSICIAN FEE - EMG PF-EMG HEMIDIAPHRAGM EACH 95866 $153.00 960 $107.10 $76.50 $122.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400269 PHYSICIAN FEE - EMG PF-EMG ISCHEMIC LIMB EXERCISE EACH 95875 $147.00 960 $102.90 $73.50 $117.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400350 PHYSICIAN FEE - EMG PF-EMG LARYNX EACH 95865 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400038 PHYSICIAN FEE - EMG PF-EMG LIMITED STUDY EACH 95870 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400152 PHYSICIAN FEE - EMG PF-EMG NON-LIMB MUSCLE EACH 95887 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400236 PHYSICIAN FEE - EMG PF-EMG ONE EXTREMITY EACH 95860 $127.00 960 $88.90 $63.50 $101.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400475 PHYSICIAN FEE - EMG PF-EMG SINGLE FIBER DENSITY EACH 95872 $108.00 960 $75.60 $54.00 $86.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400053 PHYSICIAN FEE - EMG PF-EMG THORASIC PARASPINAL EACH 95869 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400343 PHYSICIAN FEE - EMG PF-EMG TWO EXTREMITIES EACH 95861 $202.00 960 $141.40 $101.00 $161.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400079 PHYSICIAN FEE - EMG PF-GUIDE NERV DESTR ELEC STIM EACH 95873 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400061 PHYSICIAN FEE - EMG PF-GUIDE NERV DESTR NEEDLE EMG EACH 95874 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400376 PHYSICIAN FEE - EMG PF-MOTION ANALYSIS VIDEO/3D EACH 96000 $209.00 960 $146.30 $104.50 $167.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400434 PHYSICIAN FEE - EMG PF-MOTION TEST W/FT PRESS MEAS EACH 96001 $284.00 960 $198.80 $142.00 $227.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400004 PHYSICIAN FEE - EMG PF-MOTOR/SENS N CONDUCT TEST EACH 95905 $8.00 960 $5.60 $4.00 $6.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400178 PHYSICIAN FEE - EMG PF-MUSC TEST DONE W/N TEST CMP EACH 95886 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400012 PHYSICIAN FEE - EMG PF-MUSC TST DONE W/NERV TST LM EACH 95885 $46.00 960 $32.20 $23.00 $36.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400483 PHYSICIAN FEE - EMG PF-NERVE CONDUCT STUDIES 11-12 EACH 95912 $236.00 960 $165.20 $118.00 $188.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400244 PHYSICIAN FEE - EMG PF-NERVE CONDUCT STUDIES 1-2 EACH 95907 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400491 PHYSICIAN FEE - EMG PF-NERVE CONDUCT STUDIES 13+ EACH 95913 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400285 PHYSICIAN FEE - EMG PF-NERVE CONDUCT STUDIES 3-4 EACH 95908 $119.00 960 $83.30 $59.50 $95.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400319 PHYSICIAN FEE - EMG PF-NERVE CONDUCT STUDIES 5-6 EACH 95909 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400418 PHYSICIAN FEE - EMG PF-NERVE CONDUCT STUDIES 7-8 EACH 95910 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400459 PHYSICIAN FEE - EMG PF-NERVE CONDUCT STUDIES 9-10 EACH 95911 $208.00 960 $145.60 $104.00 $166.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400145 PHYSICIAN FEE - EMG PF-NEUROMUSCULAR JUNCTION TEST EACH 95937 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400426 PHYSICIAN FEE - EMG PF-PHYS REVIEW OF MOTION TESTS EACH 96004 $278.00 960 $194.60 $139.00 $222.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400848 PHYSICIAN FEE - EMG PF-QUAN PUPLMTRY PHY/QHP EACH 95919 $16.00 960 $11.20 $8.00 $12.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400095 PHYSICIAN FEE - EMG PF-SSEP LOWER LIMBS EACH 95926 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400103 PHYSICIAN FEE - EMG PF-SSEP TRUNK/HEAD EACH 95927 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400194 PHYSICIAN FEE - EMG PF-SSEP UPPER & LOWER LIMBS EACH 95938 $114.00 960 $79.80 $57.00 $91.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400129 PHYSICIAN FEE - EMG PF-SSEP UPPER LIMBS EACH 95925 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99400855 PHYSICIAN FEE - EMG PF-US NRV&ACC STRUX 1XTR COMPR EACH 76883 $37.00 960 $25.90 $18.50 $29.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205430 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ABD PARACENTESIS W/IMAGING EACH 49083 $275.00 960 $192.50 $137.50 $220.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201835 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ABLAT RENL TUM PERC CRYO LT EACH 50593 "$1,185.00 " 960 $829.50 $592.50 $948.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201843 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ABLAT RENL TUM PERC CRYO RT EACH 50593 "$1,185.00 " 960 $829.50 $592.50 $948.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206024 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ARTHROCENT ASP/INJ JT SM LT EACH 20600 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206032 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ARTHROCENT ASP/INJ JT SM RT EACH 20600 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205927 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ASP CYST BREAST LT EACH 19000 $113.00 960 $79.10 $56.50 $90.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205935 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ASP CYST BREAST RT EACH 19000 $113.00 960 $79.10 $56.50 $90.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201694 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ASP/INJ CYST RENAL PERC LT EACH 50390 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201702 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ASP/INJ CYST RENAL PERC RT EACH 50390 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206131 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ASP/INJ GANGLION CYST LT EACH 20612 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206149 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ASP/INJ GANGLION CYST RT EACH 20612 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205539 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ASSESS CYST CONTRAST INJECT EACH 49424 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204367 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-AV FISTULA GRAFT W/STENT EACH 36906 "$1,354.00 " 960 $947.80 $677.00 "$1,083.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204342 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-AV FISTULA GRAFT DECLOT EACH 36904 $980.00 960 $686.00 $490.00 $784.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204359 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-AV FISTULA GRAFT W/ANGIO EACH 36905 "$1,167.00 " 960 $816.90 $583.50 $933.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209820 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-BAL ANGIOP CTR DIALYSIS SEG EACH 36907 $389.00 960 $272.30 $194.50 $311.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201942 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-BALLOON DILATION URETER LT EACH 50706 $468.00 960 $327.60 $234.00 $374.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201967 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-BALLOON DILATION URETER RT EACH 50706 $468.00 960 $327.60 $234.00 $374.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205448 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-BIOPSY ABDOMINAL MASS EACH 49180 $215.00 960 $150.50 $107.50 $172.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205893 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-BIOPSY OF HEART LINING EACH 93505 $613.00 960 $429.10 $306.50 $490.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205588 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-BIOPSY OF THYROID EACH 60100 $202.00 960 $141.40 $101.00 $161.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200035 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-BONE BX TROCAR/NDL SUPERFIC EACH 0201T "$5,042.00 " 960 "$3,529.40 " "$2,521.00 " "$4,033.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200043 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-BONE BX TROCAR/NEEDLE DEEP EACH 0234T $314.00 960 $219.80 $157.00 $251.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205612 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-BRAIN CANAL SHUNT PROCEDURE EACH 61070 $153.00 960 $107.10 $76.50 $122.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206917 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CATH ABD/PEL 1ST ORDER RT EACH 36245 $638.00 960 $446.60 $319.00 $510.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206933 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CATH ABD/PEL 2ND ORDER LT EACH 36246 $697.00 960 $487.90 $348.50 $557.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206941 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CATH ABD/PEL 2ND ORDER RT EACH 36246 $697.00 960 $487.90 $348.50 $557.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206958 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CATH ABD/PEL 3RD ORDER LT EACH 36247 $804.00 960 $562.80 $402.00 $643.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206966 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CATH ABD/PEL 3RD ORDER RT EACH 36247 $804.00 960 $562.80 $402.00 $643.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205554 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CHANGE G-TUBE TO G-J PERC EACH 49446 $380.00 960 $266.00 $190.00 $304.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209903 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CHEMO IA PUSH BY PHYSICIAN EACH 96420 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208376 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CINE/VIDEO X-RAYS EACH 76120 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207337 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CISTERNOGRAPHY POS CONTR SI EACH 70015 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207295 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CONTRAST X-RAY BLADDER EACH 38790 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209622 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CONTRAST X-RAY BLADDER EACH 74430 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205299 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CONVERSION EXT BIL DRG CATH EACH 47535 $504.00 960 $352.80 $252.00 $403.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208384 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CT 3D RENDERING W/PROCESS EACH 76377 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208475 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CT GUIDED NEEDLE PLACEMENT EACH 77012 $178.00 960 $124.60 $89.00 $142.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208483 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CT GUIDED TISSUE ABLATION EACH 77013 $465.00 960 $325.50 $232.50 $372.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209507 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CT UPPER EXT W&WO CON RT EACH 73202 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209366 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CT UPR EXT W&W/O CONT BILAT EACH 73202 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209499 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-CT UPR EXT W&W/O CONT LT EACH 73202 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204920 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DECLOT VASCULAR DEVICE EACH 36593 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202528 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DESTROY C/TH FACET ADDL LT EACH 64634 $176.00 960 $123.20 $88.00 $140.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202536 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DESTROY C/TH FACET ADDL RT EACH 64634 $176.00 960 $123.20 $88.00 $140.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202494 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DESTROY C/TH FACET JNT LT EACH 64633 $503.00 960 $352.10 $251.50 $402.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202502 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DESTROY C/TH FACET JNT RT EACH 64633 $503.00 960 $352.10 $251.50 $402.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202569 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DESTROY L/S FACET ADDL LT EACH 64636 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202577 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DESTROY L/S FACET ADDL RT EACH 64636 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202544 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DESTROY L/S FACET JNT LT EACH 64635 $504.00 960 $352.80 $252.00 $403.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202551 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DESTROY L/S FACET JNT RT EACH 64635 $504.00 960 $352.80 $252.00 $403.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205703 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DIL IC VASOPASM DIFF ADDON EACH 61642 $909.00 960 $636.30 $454.50 $727.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205695 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DIL IC VASOPASM SAME ADDON EACH 61641 $455.00 960 $318.50 $227.50 $364.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205687 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DILATE IC VASOSPASM INIT EACH 61640 "$1,295.00 " 960 $906.50 $647.50 "$1,036.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209614 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DISCOGRAPHY CERV/THOR SPINE EACH 72285 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205901 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DOPPLER ARTERIAL EXT EACH 93922 $32.00 960 $22.40 $16.00 $25.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204490 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DRAIN CEREBRO SPINAL FLUID EACH 62272 $266.00 960 $186.20 $133.00 $212.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205414 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-DRAINAGE OF ABDOMEN EACH 48000 "$5,348.00 " 960 "$3,743.60 " "$2,674.00 " "$4,278.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205398 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOLUMINAL BX BILIARY TREE EACH 47543 $369.00 960 $258.30 $184.50 $295.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204581 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVAS ILIAC A DEV ADDON EACH 34808 $574.00 960 $401.80 $287.00 $459.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205620 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVASC TEMPRY VESSEL OCCL EACH 61623 "$1,679.00 " 960 "$1,175.30 " $839.50 "$1,343.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204599 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVASC VISC AORTA 1 GRAFT EACH 34841 "$3,662.00 " 960 "$2,563.40 " "$1,831.00 " "$2,929.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209051 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVEN LASER 1ST VEIN LT EACH 36478 $765.00 960 $535.50 $382.50 $612.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209069 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVEN LASER 1ST VEIN RT EACH 36478 $765.00 960 $535.50 $382.50 $612.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209077 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVEN LASER VEIN ADDON LT EACH 36479 $375.00 960 $262.50 $187.50 $300.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209085 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVEN LASER VEIN ADDON RT EACH 36479 $375.00 960 $262.50 $187.50 $300.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209036 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVEN RF VEIN ADD-ON LT EACH 36476 $369.00 960 $258.30 $184.50 $295.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209044 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVEN RF VEIN ADD-ON RT EACH 36476 $369.00 960 $258.30 $184.50 $295.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209002 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVENOUS RF 1ST VEIN LT EACH 36475 $770.00 960 $539.00 $385.00 $616.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209010 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ENDOVENOUS RF 1ST VEIN RT EACH 36475 $770.00 960 $539.00 $385.00 $616.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205729 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-EVASC PRLNG ADMN RX AGNT 1 EACH 61650 "$1,706.00 " 960 "$1,194.20 " $853.00 "$1,364.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205307 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-EXCHANGE BILIARY DRG CATH EACH 47536 $340.00 960 $238.00 $170.00 $272.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205513 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-EXCHANGE DRAINAGE CATHETER EACH 49423 $184.00 960 $128.80 $92.00 $147.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201801 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-EXCHANGE NEP CATH LT EACH 50435 $258.00 960 $180.60 $129.00 $206.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201827 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-EXCHANGE NEP CATH RT EACH 50435 $258.00 960 $180.60 $129.00 $206.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201975 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-EXPLORE ADRENAL GLAND LT EACH 60540 "$3,001.00 " 960 "$2,100.70 " "$1,500.50 " "$2,400.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201983 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-EXPLORE ADRENAL GLAND RT EACH 60540 "$3,001.00 " 960 "$2,100.70 " "$1,500.50 " "$2,400.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205133 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-FEM/POPL REVAS W/TLA EACH 37224 "$1,235.00 " 960 $864.50 $617.50 $988.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205141 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-FEM/POPL REVASC W/STENT EACH 37226 "$1,441.00 " 960 "$1,008.70 " $720.50 "$1,152.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200001 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-FNA W/IMAGE EACH 0075T $186.00 960 $130.20 $93.00 $148.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200019 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-GUIDE CATHET FLUID DRAINAGE EACH 0076T $435.00 960 $304.50 $217.50 $348.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209127 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ILIAC ADDL VESSEL W/STNT LT EACH 37223 $591.00 960 $413.70 $295.50 $472.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209135 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ILIAC ADDL VESSEL W/STNT RT EACH 37223 $591.00 960 $413.70 $295.50 $472.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209101 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ILIAC ADDL VESSL W/ANGIO LT EACH 37222 $512.00 960 $358.40 $256.00 $409.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209119 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ILIAC ADDL VESSL W/ANGIO RT EACH 37222 $512.00 960 $358.40 $256.00 $409.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205117 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ILIAC REVASC EACH 37220 "$1,107.00 " 960 $774.90 $553.50 $885.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205125 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-ILIAC REVASC W/STENT EACH 37221 "$1,369.00 " 960 $958.30 $684.50 "$1,095.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201991 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ ANES NERVE TRIGEMIN LT EACH 64400 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202007 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ ANES NERVE TRIGEMIN RT EACH 64400 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206271 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ ARTHRO SACRO WO ANES LT EACH 27096 $217.00 960 $151.90 $108.50 $173.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206289 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ ARTHRO SACRO WO ANES RT EACH 27096 $217.00 960 $151.90 $108.50 $173.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206321 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ ARTHROGRAM ANKLE LT EACH 27648 $139.00 960 $97.30 $69.50 $111.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206339 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ ARTHROGRAM ANKLE RT EACH 27648 $139.00 960 $97.30 $69.50 $111.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205257 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ CHOLANGIOGRAM EX ACCESS EACH 47531 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205265 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ CHOLANGIOGRAM NEW ACC EACH 47532 $547.00 960 $382.90 $273.50 $437.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202213 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ EPIDUR CERV/THOR ADD LT EACH 64480 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202221 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ EPIDUR CERV/THOR ADD RT EACH 64480 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202197 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ EPIDUR CREV/THOR SGL LT EACH 64479 $340.00 960 $238.00 $170.00 $272.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202593 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ FOR TEAR SAC X-RAY LT EACH 68850 $133.00 960 $93.10 $66.50 $106.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202601 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ FOR TEAR SAC X-RAY RT EACH 68850 $133.00 960 $93.10 $66.50 $106.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202262 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ FORAMEN EPIDUR ADDON LT EACH 64484 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202270 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ FORAMEN EPIDUR ADDON RT EACH 64484 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202247 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ FORAMEN EPIDUR L/S LT EACH 64483 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201769 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ NEPH/URETERO EXT ACC LT EACH 50431 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201777 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ NEPH/URETERO EXT ACC RT EACH 50431 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201736 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ NEPH/URETERO NEW ACC LT EACH 50430 $399.00 960 $279.30 $199.50 $319.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201751 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ NEPH/URETERO NEW ACC RT EACH 50430 $399.00 960 $279.30 $199.50 $319.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202288 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT C/T 1 LT EACH 64490 $276.00 960 $193.20 $138.00 $220.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202312 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT C/T 2 LT EACH 64491 $156.00 960 $109.20 $78.00 $124.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202338 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT C/T 3 LT EACH 64492 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202346 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT C/T 3 RT EACH 64492 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202353 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT L/S 1 LT EACH 64493 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202361 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT L/S 1 RT EACH 64493 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202387 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT L/S 2 LT EACH 64494 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202395 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT L/S 2 RT EACH 64494 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202403 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT L/S 3 LT EACH 64495 $136.00 960 $95.20 $68.00 $108.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202411 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ PARAVERT F JNT L/S 3 RT EACH 64495 $136.00 960 $95.20 $68.00 $108.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205786 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY "PF-INJ SPINE DISK, XRAY LUMBAR" EACH 62290 $406.00 960 $284.20 $203.00 $324.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205992 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ TENDON ORIGIN/INSERT LT EACH 20551 $103.00 960 $72.10 $51.50 $82.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206008 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ TENDON ORIGIN/INSERT RT EACH 20551 $103.00 960 $72.10 $51.50 $82.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206602 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ VENOGRAM EXTREMITY LT EACH 36005 $129.00 960 $90.30 $64.50 $103.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206610 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJ VENOGRAM EXTREMITY RT EACH 36005 $129.00 960 $90.30 $64.50 $103.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209317 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJECT LYMPHATIC X-RAY RT EACH 38790 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206974 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJECT THERAPY OF VEIN LT EACH 36470 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206982 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJECT THERAPY OF VEIN RT EACH 36470 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205604 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INJECTION INTO BRAIN CANAL EACH 61055 $319.00 960 $223.30 $159.50 $255.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204789 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INS CATH REN ART 1ST UNILAT EACH 36251 $693.00 960 $485.10 $346.50 $554.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211735 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INSERT HEPATIC SHUNT (TIPS) EACH 37182 "$2,100.00 " 960 "$1,470.00 " "$1,050.00 " "$1,680.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201090 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INSERT TUN IP CATH PERC EACH 36245 $638.00 960 $446.60 $319.00 $510.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205497 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INSERT TUN IP CATH PERC EACH 49418 $520.00 960 $364.00 $260.00 $416.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204854 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INSERT TUNNEL CV CATH W/PRT EACH 36561 $893.00 960 $625.10 $446.50 $714.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204847 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INSERT TUNNELED CV CATH W/O EACH 36558 $686.00 960 $480.20 $343.00 $548.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205018 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INSERT VASC VENA CAVA FILTR EACH 37191 $584.00 960 $408.80 $292.00 $467.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201710 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INSTLL RX AGNT RNL TUB LT EACH 50391 $260.00 960 $182.00 $130.00 $208.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201728 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INSTLL RX AGNT RNL TUB RT EACH 50391 $260.00 960 $182.00 $130.00 $208.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205752 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INTERDISCAL PERQ ASPIR DX EACH 62267 $402.00 960 $281.40 $201.00 $321.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205679 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INTRACRAN ANGIOPLST W/STENT EACH 61635 "$4,276.00 " 960 "$2,993.20 " "$2,138.00 " "$3,420.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205653 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INTRACRANIAL ANGIOPLASTY EACH 61630 "$3,939.00 " 960 "$2,757.30 " "$1,969.50 " "$3,151.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204318 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INTRO CATH DIALYSIS W/ANGIO EACH 36902 $638.00 960 $446.60 $319.00 $510.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204326 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-INTRO CATH DIALYSIS W/STENT EACH 36903 $846.00 960 $592.20 $423.00 $676.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207956 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-LYMPH VESSEL X-RAY TRUNK BI EACH 75807 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207949 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-LYMPH VESSEL XRAY TRUNK UNI EACH 75805 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204938 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-MECH REMOV TUNNELED CV CATH EACH 36595 $473.00 960 $331.10 $236.50 $378.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208707 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-MECH REMOV TUNNELED CV CATH EACH 36596 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208509 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-MRI FOR TISSUE ABLATION EACH 77022 $504.00 960 $352.80 $252.00 $403.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208491 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-MRI GUIDE NDL PLACE EACH 77021 $178.00 960 $124.60 $89.00 $142.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205794 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-MYELOGRAPHY LUMBAR INJ CV EACH 62302 $309.00 960 $216.30 $154.50 $247.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205836 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-MYELOGRAPHY LUMBAR INJ LS EACH 62305 $317.00 960 $221.90 $158.50 $253.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205828 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-MYELOGRAPHY LUMBAR INJ TH EACH 62304 $306.00 960 $214.20 $153.00 $244.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209333 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-MYELOGRAPHY POSTER FOSSA SI EACH 70010 $152.00 960 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202106 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK ILIO-ING/HYPOGI LT EACH 64425 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202114 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK ILIO-ING/HYPOGI RT EACH 64425 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202049 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ BRACH PLEXUS LT EACH 64415 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202056 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ BRACH PLEXUS RT EACH 64415 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202478 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ CELIAC PELUS LT EACH 64530 $247.00 960 $172.90 $123.50 $197.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202486 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ CELIAC PELUS RT EACH 64530 $247.00 960 $172.90 $123.50 $197.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202072 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ INTERCST MLT LT EACH 64421 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202080 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ INTERCST MLT RT EACH 64421 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202064 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ INTERCST SNG RT EACH 64420 $152.00 960 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202015 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ OCCIPITAL LT EACH 64405 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202031 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ OCCIPITAL RT EACH 64405 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202122 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ PUDENDAL LT EACH 64430 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202130 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ PUDENDAL RT EACH 64430 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202148 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ SCIATIC SNG LT EACH 64445 $189.00 960 $132.30 $94.50 $151.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202155 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK INJ SCIATIC SNG RT EACH 64445 $189.00 960 $132.30 $94.50 $151.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202452 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK LUMBAR/THORACIC LT EACH 64520 $222.00 960 $155.40 $111.00 $177.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202460 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK LUMBAR/THORACIC RT EACH 64520 $222.00 960 $155.40 $111.00 $177.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202189 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK OTHER PERIPHERAL RT EACH 64450 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202429 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK SPENOPALAT GANGL LT EACH 64505 $294.00 960 $205.80 $147.00 $235.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96202437 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-N BLOCK SPENOPALAT GANGL RT EACH 64505 $294.00 960 $205.80 $147.00 $235.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205208 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-NEEDLE BIOPSY OF LIVER EACH 47000 $228.00 960 $159.60 $114.00 $182.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205422 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-NEEDLE BIOPSY PANCREAS EACH 48102 $611.00 960 $427.70 $305.50 $488.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209192 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-OPEN/PERQ STENT 1ST LT EACH 37236 "$1,220.00 " 960 $854.00 $610.00 $976.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209200 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-OPEN/PERQ STENT 1ST RT EACH 37236 "$1,220.00 " 960 $854.00 $610.00 $976.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209218 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-OPEN/PERQ STENT ADD LT EACH 37237 $588.00 960 $411.60 $294.00 $470.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209226 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-OPEN/PERQ STENT ADD RT EACH 37237 $588.00 960 $411.60 $294.00 $470.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209267 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-OPEN/PERQ STENT ADDL LT EACH 37239 $411.00 960 $287.70 $205.50 $328.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209275 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-OPEN/PERQ STENT ADDL RT EACH 37239 $411.00 960 $287.70 $205.50 $328.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209242 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-OPEN/PERQ STENT SAME LT EACH 37238 $839.00 960 $587.30 $419.50 $671.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209259 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-OPEN/PERQ STENT SAME RT EACH 37238 $839.00 960 $587.30 $419.50 $671.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209176 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PER REVASC ADD VSL W/AT LT EACH 37233 $878.00 960 $614.60 $439.00 $702.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209184 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PER REVASC ADD VSL W/AT RT EACH 37233 $878.00 960 $614.60 $439.00 $702.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209143 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PER REVASC ADD VSL W/TL LT EACH 37232 $547.00 960 $382.90 $273.50 $437.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209150 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PER REVASC ADD VSL W/TL RT EACH 37232 $547.00 960 $382.90 $273.50 $437.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201785 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERC NEPH CATH LT EACH 50432 $527.00 960 $368.90 $263.50 $421.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201793 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERC NEPH CATH RT EACH 50432 $527.00 960 $368.90 $263.50 $421.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201850 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERC URETER STENT EXIST LT EACH 50693 $524.00 960 $366.80 $262.00 $419.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201868 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERC URETER STENT EXIST RT EACH 50693 $524.00 960 $366.80 $262.00 $419.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201876 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERC URETER STENT NEW LT EACH 50694 $684.00 960 $478.80 $342.00 $547.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201892 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERC URETER STENT NEW RT EACH 50694 $684.00 960 $478.80 $342.00 $547.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205216 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERCUT ABLATE LIVER RF EACH 47382 "$1,911.00 " 960 "$1,337.70 " $955.50 "$1,528.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205711 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERQ ART M-THROMBECT &/NFS EACH 61645 "$2,430.00 " 960 "$1,701.00 " "$1,215.00 " "$1,944.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200050 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERQ CERVICOTHORACIC INJECT EACH 0235T $713.00 960 $499.10 $356.50 $570.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205919 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERQ LAMOT/LAM LUMBAR EACH 0275T "$7,500.00 " 960 "$5,250.00 " "$3,750.00 " "$6,000.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200076 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERQ LUMBOSACRAL INJECTION EACH 0236T "$31,349.00 " 960 "$21,944.30 " "$15,674.50 " "$25,079.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200092 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PERQ VERTEBRAL AUGMENT CV EACH 0238T "$31,349.00 " 960 "$21,944.30 " "$15,674.50 " "$25,079.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204169 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH 2+ TH/BR ADDL LT EACH 36218 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204177 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH 2+ TH/BR ADDL RT EACH 36218 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204185 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH 3RD TH/BR ADD LT EACH 36217 $930.00 960 $651.00 $465.00 $744.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204201 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH 3RD TH/BR ADD RT EACH 36217 $930.00 960 $651.00 $465.00 $744.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206693 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH ART PULM L/R LT EACH 36014 $405.00 960 $283.50 $202.50 $324.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206701 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH ART PULM L/R RT EACH 36014 $405.00 960 $283.50 $202.50 $324.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206727 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH ART PULM SEG LT EACH 36015 $450.00 960 $315.00 $225.00 $360.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206735 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH ART PULM SEG RT EACH 36015 $450.00 960 $315.00 $225.00 $360.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204730 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH ARTERY 1ST ORD EACH 36215 $564.00 960 $394.80 $282.00 $451.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204748 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH ARTERY 2ND ORD EACH 36216 $750.00 960 $525.00 $375.00 $600.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204771 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH THORACIC AORTA EACH 36221 $557.00 960 $389.90 $278.50 $445.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206651 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH VENOUS 1ST LT EACH 36011 $420.00 960 $294.00 $210.00 $336.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206669 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH VENOUS 1ST RT EACH 36011 $420.00 960 $294.00 $210.00 $336.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206677 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH VENOUS 2ND LT EACH 36012 $467.00 960 $326.90 $233.50 $373.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206685 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH VENOUS 2ND RT EACH 36012 $467.00 960 $326.90 $233.50 $373.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209671 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH XTRNL CAROTID LT EACH 36227 $349.00 960 $244.30 $174.50 $279.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209663 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE CATH XTRNL CAROTID RT EACH 36227 $349.00 960 $244.30 $174.50 $279.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205547 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE GASTROSTOMY TUBE PERC EACH 49440 $525.00 960 $367.50 $262.50 $420.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204144 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLACE OCCLUSIVE DEVICE A/V EACH G0269 "$7,500.00 " 960 "$5,250.00 " "$3,750.00 " "$6,000.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206446 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLEURAL DRAIN W/CATH W LT EACH 32557 $388.00 960 $271.60 $194.00 $310.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206453 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLEURAL DRAIN W/CATH W RT EACH 32557 $388.00 960 $271.60 $194.00 $310.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205364 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLMT ACCESS BIL TREE SM BWL EACH 47541 $866.00 960 $606.20 $433.00 $692.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200936 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLMT BILE DUCT STENT EX ACC EACH 36222 $805.00 960 $563.50 $402.50 $644.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205331 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLMT BILE DUCT STENT EX ACC EACH 47538 $604.00 960 $422.80 $302.00 $483.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205356 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLMT BILE DUCT STNT EXT/INT EACH 47540 "$1,132.00 " 960 $792.40 $566.00 $905.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200944 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLMT BILE DUCT STNT NEW ACC EACH 36222 $805.00 960 $563.50 $402.50 $644.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205349 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLMT BILE DUCT STNT NEW ACC EACH 47539 "$1,100.00 " 960 $770.00 $550.00 $880.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205273 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PLMT BILIARY DRAIN CATH EXT EACH 47533 $678.00 960 $474.60 $339.00 $542.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209879 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PRIM ART MECH THROMBECTOMY EACH 37184 "$1,168.00 " 960 $817.60 $584.00 $934.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204987 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PRIM ART M-THROMBECT ADD-ON EACH 37185 $444.00 960 $310.80 $222.00 $355.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206586 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PSEUDOANEURYSM INJ TRT LT EACH 36002 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206594 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PSEUDOANEURYSM INJ TRT RT EACH 36002 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211586 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PUNC ABSC/HEMA/CYST/BULLA EACH 10160 $256.00 960 $179.20 $128.00 $204.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200027 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PUNCTURE DRAINAGE OF LESION EACH 0200T "$5,042.00 " 960 "$3,529.40 " "$2,521.00 " "$4,033.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205869 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PVB THORACIC CONT INFUSION EACH 64463 $213.00 960 $149.10 $106.50 $170.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205844 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-PVB THORACIC SGL INJ SITE EACH 64461 $205.00 960 $143.50 $102.50 $164.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205026 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REM ENDOV VENA CAVA FILTER EACH 37193 $922.00 960 $645.40 $461.00 $737.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201660 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REM RENAL TUBE W/ FLUORO LT EACH 50389 $139.00 960 $97.30 $69.50 $111.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201686 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REM RENAL TUBE W/ FLUORO RT EACH 50389 $139.00 960 $97.30 $69.50 $111.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206180 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REM SHOULDER FOREIGN BDY LT EACH 23330 $458.00 960 $320.60 $229.00 $366.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206198 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REM SHOULDER FOREIGN BDY RT EACH 23330 $458.00 960 $320.60 $229.00 $366.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201629 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REM STENT VIA TRANSURETH LT EACH 50386 $428.00 960 $299.60 $214.00 $342.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201637 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REM STENT VIA TRANSURETH RT EACH 50386 $428.00 960 $299.60 $214.00 $342.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204912 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REM TUNNEL CV CATH W/ PORT EACH 36590 $511.00 960 $357.70 $255.50 $408.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204904 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REM TUNNEL CV CATH W/O PORT EACH 36589 $363.00 960 $254.10 $181.50 $290.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205323 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVAL BILIARY DRG CATH EACH 47537 $249.00 960 $174.30 $124.50 $199.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205406 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVAL DUCT GLBLDR CALCULI EACH 47544 $404.00 960 $282.80 $202.00 $323.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209648 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVE CVA DEVICE OBSTRUCT EACH 75901 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208202 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVE CVA LUMEN OBSTRUCT EACH 75902 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211743 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVE HEPATIC SHUNT (TIPS) EACH 37183 $964.00 960 $674.80 $482.00 $771.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205042 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVE INTRVAS FOREIGN BODY EACH 37197 $808.00 960 $565.60 $404.00 $646.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209325 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVE KIDNEY STONE LT <2CM EACH 50080 "$1,849.00 " 960 "$1,294.30 " $924.50 "$1,479.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201520 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVE KIDNEY STONE LT >2CM EACH 50081 "$2,981.00 " 960 "$2,086.70 " "$1,490.50 " "$2,384.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201512 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVE KIDNEY STONE RT <2CM EACH 50080 "$1,849.00 " 960 "$1,294.30 " $924.50 "$1,479.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201546 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVE KIDNEY STONE RT >2CM EACH 50081 "$2,981.00 " 960 "$2,086.70 " "$1,490.50 " "$2,384.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204565 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REMOVE LUNG CATHETER EACH 32552 $418.00 960 $292.60 $209.00 $334.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201553 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-RENAL BIOPSY PERC LT EACH 50200 $328.00 960 $229.60 $164.00 $262.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201561 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-RENAL BIOPSY PERC RT EACH 50200 $328.00 960 $229.60 $164.00 $262.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205562 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REPLACE G/C TUBE PERC EACH 49450 $171.00 960 $119.70 $85.50 $136.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205570 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-REPLACE G-J TUBE PERC EACH 49452 $354.00 960 $247.80 $177.00 $283.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205463 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SCLEROTX FLUID COLLECTION EACH 49185 $312.00 960 $218.40 $156.00 $249.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206768 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CATH CC/IA UNI W/ANG LT EACH 36223 $941.00 960 $658.70 $470.50 $752.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206776 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CATH CC/IA UNI W/ANG RT EACH 36223 $941.00 960 $658.70 $470.50 $752.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206883 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CATH IB EA UNI W/ANG LT EACH 36228 $724.00 960 $506.80 $362.00 $579.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206891 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CATH IB EA UNI W/ANG RT EACH 36228 $724.00 960 $506.80 $362.00 $579.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206792 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CATH ICC UNI W/ANGIO LT EACH 36224 "$1,063.00 " 960 $744.10 $531.50 $850.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206800 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CATH ICC UNI W/ANGIO RT EACH 36224 "$1,063.00 " 960 $744.10 $531.50 $850.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204219 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY "PF-SEL CATH PL TH AORTA,W/A BI" EACH 36222 $805.00 962 $563.50 $402.50 $644.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204235 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CATH PLACE ICC W/A BI EACH 36224 "$1,063.00 " 962 $744.10 $531.50 $850.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206818 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CATH SC/IA UNI W/ANG LT EACH 36225 $934.00 960 $653.80 $467.00 $747.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206826 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CATH SC/IA UNI W/ANG RT EACH 36225 $934.00 960 $653.80 $467.00 $747.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204227 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CTH PLACE CC/IA W/A BI EACH 36223 $941.00 962 $658.70 $470.50 $752.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204276 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SEL CTH PLACE IB EA W/A BI EACH 36228 $724.00 962 $506.80 $362.00 $579.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205760 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-SPINAL FLUID TAP DIAGNOSTIC EACH 62270 $180.00 960 $126.00 $90.00 $144.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205091 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-STENT PLACEMT ANTE CAROTID EACH 37218 "$2,305.00 " 960 "$1,613.50 " "$1,152.50 " "$1,844.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209838 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-STENT PLMT CTR DIALYS SEG EACH 36908 $558.00 960 $390.60 $279.00 $446.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206412 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-THORACEN-PLEURAL W/GUIDE LT EACH 32555 $283.00 960 $198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206420 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-THORACEN-PLEURAL W/GUIDE RT EACH 32555 $283.00 960 $198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206396 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-THORACOST INS CHEST TUBE LT EACH 32551 $424.00 960 $296.80 $212.00 $339.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206404 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-THORACOST INS CHEST TUBE RT EACH 32551 $424.00 960 $296.80 $212.00 $339.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205067 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-THROMBLYTIC ART/VEN THERAPY EACH 37213 $623.00 960 $436.10 $311.50 $498.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209846 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-THROMBOLYTIC ART THERAPY EACH 37211 "$1,055.00 " 960 $738.50 $527.50 $844.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205059 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-THROMBOLYTIC VENOUS THERAPY EACH 37212 $911.00 960 $637.70 $455.50 $728.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205158 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-TIB/PER REVASC W/TLA EACH 37228 "$1,498.00 " 960 "$1,048.60 " $749.00 "$1,198.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205646 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-TRANSCATH OCCLUSION NON-CNS EACH 61626 "$2,566.00 " 960 "$1,796.20 " "$1,283.00 " "$2,052.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205075 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-TRANSCATH STENT CCA W/EPS EACH 37215 "$2,782.00 " 960 "$1,947.40 " "$1,391.00 " "$2,225.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205083 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-TRANSCATH STENT CCA W/O EP EACH 37216 "$2,570.00 " 960 "$1,799.00 " "$1,285.00 " "$2,056.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209929 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-TRANSCATHETER BIOPSY EACH 37200 $555.00 960 $388.50 $277.50 $444.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209762 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-TRLUML BAL ANGIO 1 VEIN EACH 37248 $791.00 960 $553.70 $395.50 $632.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209747 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-TRLUML BAL ANGIO 1ST ART EACH 37246 $947.00 960 $662.90 $473.50 $757.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204391 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-TRLUML BAL ANGIO ADD ART EACH 37247 $474.00 960 $331.80 $237.00 $379.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201926 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-URETER EMBOLIZATION LT EACH 50705 $468.00 960 $327.60 $234.00 $374.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201934 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-URETER EMBOLIZATION RT EACH 50705 $468.00 960 $327.60 $234.00 $374.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201900 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-URETER STENT W/NEPH CTH LT EACH 50695 $879.00 960 $615.30 $439.50 $703.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96201918 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-URETER STENT W/NEPH CTH RT EACH 50695 $879.00 960 $615.30 $439.50 $703.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208400 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-US ABDOMEN LIMITED EACH 76705 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208426 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-US GUIDE TISSUE ABLATION EACH 76940 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207329 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-US GUIDE VASCULAR ACCESS EACH 76937 $37.00 960 $25.90 $18.50 $29.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208343 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-US GUIDED ABSC DRAINAGE EACH 75989 $142.00 960 $99.40 $71.00 $113.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208434 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-US GUIDED NEEDLE PLACE S&I EACH 76942 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211289 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VASC EMBOL/OCCLUDE ART LT EACH 37242 "$1,272.00 " 960 $890.40 $636.00 "$1,017.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211297 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VASC EMBOL/OCCLUDE ART RT EACH 37242 "$1,272.00 " 960 $890.40 $636.00 "$1,017.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211321 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VASC EMBOL/OCCLUDE BLEED LT EACH 37244 "$1,710.00 " 960 "$1,197.00 " $855.00 "$1,368.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211347 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VASC EMBOL/OCCLUDE BLEED RT EACH 37244 "$1,710.00 " 960 "$1,197.00 " $855.00 "$1,368.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211305 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VASC EMBOL/OCCLUDE ORGAN LT EACH 37243 "$1,447.00 " 960 "$1,012.90 " $723.50 "$1,157.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211313 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VASC EMBOL/OCCLUDE ORGAN RT EACH 37243 "$1,447.00 " 960 "$1,012.90 " $723.50 "$1,157.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211255 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VASC EMBOL/OCCLUDE VEN LT EACH 37241 "$1,135.00 " 960 $794.50 $567.50 $908.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96211271 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VASC EMBOL/OCCLUDE VEN RT EACH 37241 "$1,135.00 " 960 $794.50 $567.50 $908.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208129 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VEIN X-RAY EYE SOCKET EACH 75880 $86.00 960 $60.20 $43.00 $68.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208038 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VEIN X-RAY KIDNEY EACH 75831 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208137 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VEIN XRAY LIVER W/HEMODYNAM EACH 75885 $168.00 960 $117.60 $84.00 $134.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208145 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VEIN XRAY LIVER W/O HEMODYN EACH 75887 $168.00 960 $117.60 $84.00 $134.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208087 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VEIN X-RAY NECK EACH 75860 $138.00 960 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208095 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VEIN X-RAY SKULL EACH 75870 $157.00 960 $109.90 $78.50 $125.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208103 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VEIN X-RAY SKULL EPIDURAL EACH 75872 $138.00 960 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207980 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VEIN X-RAY SPLEEN/LIVER EACH 75810 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208053 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VENOGRAPHY RENAL BILAT EXAM EACH 75833 $186.00 960 $130.20 $93.00 $148.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204995 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VENOUS MECH THROMBECTOMY EACH 37187 "$1,053.00 " 960 $737.10 $526.50 $842.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96205000 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VENOUS M-THROMBECTMY ADD-ON EACH 37188 $758.00 960 $530.60 $379.00 $606.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209598 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VENOUS SAMPLING BY CATH LT EACH 75893 $67.00 960 $46.90 $33.50 $53.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209606 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VENOUS SAMPLING BY CATH RT EACH 75893 $67.00 960 $46.90 $33.50 $53.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96200084 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-VERTEBROPLASTY ADDL INJECT EACH 0237T "$31,349.00 " 960 "$21,944.30 " "$15,674.50 " "$25,079.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206461 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XPOSE ENDOPROSTH FEMORL LT EACH 34812 $582.00 960 $407.40 $291.00 $465.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206479 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XPOSE ENDOPROSTH FEMORL RT EACH 34812 $582.00 960 $407.40 $291.00 $465.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208368 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ABSC SINUS/FISTULA S&I EACH 76080 $64.00 960 $44.80 $32.00 $51.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207840 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANG VISC W/WO FLUSH S&I EACH 75726 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207865 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO ADRENAL BI S&I EACH 75733 $153.00 960 $107.10 $76.50 $122.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207857 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO ADRENAL UNILAT S&I EACH 75731 $138.00 960 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207824 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO EXTREMITY BI S&I EACH 75716 $183.00 960 $128.10 $91.50 $146.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207816 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO EXTREMITY UNI S&I EACH 75710 $175.00 960 $122.50 $87.50 $140.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207923 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO INT MAMMARY S&I EACH 75756 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207915 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO PULM NONSEL S&I EACH 75746 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207899 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO PULM SEL BI S&I EACH 75743 $183.00 960 $128.10 $91.50 $146.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207881 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO PULM SEL UNI S&I EACH 75741 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207931 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO SEL ADD VESSEL S&I EACH 75774 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207808 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIO SPINAL SELECT S&I EACH 75705 $322.00 960 $225.40 $161.00 $257.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207873 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ANGIOGRAM PELVIC S&I EACH 75736 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207782 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR AORTO ABD W LOW EXT S&I EACH 75630 $165.00 960 $115.50 $82.50 $132.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207758 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR AORTO THORACIC W SER S&I EACH 75605 $139.00 960 $97.30 $69.50 $111.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207774 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR AORTOGRAM ABD W/SER S&I EACH 75625 $152.00 960 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207741 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR AORTOGRAM THORACIC S&I EACH 75600 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209341 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHRO SHOULDER BI S&I EACH 73040 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209382 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROG SHOULDER S&I LT EACH 73040 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209408 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROG SHOULDER S&I RT EACH 73040 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207527 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM ANKLE BIL S&I EACH 73615 $70.00 960 $49.00 $35.00 $56.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209564 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM ANKLE S&I LT EACH 73615 $70.00 960 $49.00 $35.00 $56.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209572 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM ANKLE S&I RT EACH 73615 $70.00 960 $49.00 $35.00 $56.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207444 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM ELBOW BIL S&I EACH 73085 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209424 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM ELBOW S&I LT EACH 73085 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209432 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM ELBOW S&I RT EACH 73085 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207477 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM HIP BIL S&I EACH 73525 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209523 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM HIP S&I LT EACH 73525 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209531 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM HIP S&I RT EACH 73525 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207519 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM KNEE BIL S&I EACH 73580 $81.00 960 $56.70 $40.50 $64.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209549 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM KNEE S&I LT EACH 73580 $81.00 960 $56.70 $40.50 $64.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209556 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM KNEE S&I RT EACH 73580 $81.00 960 $56.70 $40.50 $64.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207360 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM TMJ EACH 70332 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207451 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM WRIST BIL S&I EACH 73115 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209457 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM WRIST S&I LT EACH 73115 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96209465 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ARTHROGRAM WRIST S&I RT EACH 73115 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208335 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR CHANGE TUBE DRN CATH S&I EACH 75984 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207667 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR CYSTOURETHROGRAM RETRO EACH 74450 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207675 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR CYSTOURETHROGRM VOID S&I EACH 74455 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208277 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ENDO RPR THORAC PROX S&I EACH 75958 $518.00 960 $362.60 $259.00 $414.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208244 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ENDO RPR THORAC W/LT S&I EACH 75956 $922.00 960 $645.40 $461.00 $737.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208269 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ENDO RPR THORAC WO L S&I EACH 75957 $792.00 960 $554.40 $396.00 $633.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208285 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ENDV RPR THORAC DIST S&I EACH 75959 $462.00 960 $323.40 $231.00 $369.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207584 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR ERCP BILIARY&PANCR S&I EACH 74330 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207717 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR HYSTEROSALPINGOGRAM S&I EACH 74740 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207428 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR MYELOGRAM >2 REGIONS S&I EACH 72270 $167.00 960 $116.90 $83.50 $133.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207386 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR MYELOGRAM CERV SPINE S&I EACH 72240 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207402 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR MYELOGRAM LUMB SPINE S&I EACH 72265 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207394 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR MYELOGRAM THOR SP S&I EACH 72255 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207964 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR SHUNTOGRAM NONVAS S&I EACH 75809 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207378 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR SIALOGRAM S&I EACH 70390 $46.00 960 $32.20 $23.00 $36.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208194 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR TRANSCATH ANGIO EXI CATH EACH 75898 $136.00 960 $95.20 $68.00 $108.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208301 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR TRANSCATH BIOPSY S&I EACH 75970 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208178 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR TRANSCATH EMBOLIZAT S&I EACH 75894 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207642 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR UROGRAM ANTEGRADE S&I EACH 74425 $60.00 960 $42.00 $30.00 $48.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208012 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR VENACAVAGRM INFERIOR S&I EACH 75825 $142.00 960 $99.40 $71.00 $113.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208020 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR VENACAVAGRM SUPERIOR S&I EACH 75827 $142.00 960 $99.40 $71.00 $113.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208160 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR VENO HEPATIC WO HEMO S&I EACH 75891 $133.00 960 $93.10 $66.50 $106.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208079 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR VENOGRAM ADRENAL BI S&I EACH 75842 $181.00 960 $126.70 $90.50 $144.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208004 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR VENOGRAM EXT BI S&I EACH 75822 $166.00 960 $116.20 $83.00 $132.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207998 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR VENOGRAM EXT UNI S&I EACH 75820 $127.00 960 $88.90 $63.50 $101.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208152 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-XR VENOGRAM HEPATIC W/HEMO EACH 75889 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207634 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY BILE DUCT DILATION EACH 74363 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207568 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY BILE DUCT ENDOSCOPY EACH 74328 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207683 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY EXAM OF KIDNEY LESION EACH 74470 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207659 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY EXAM OF PENIS EACH 74445 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207733 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY EXAM OF PERINEUM EACH 74775 $75.00 960 $52.50 $37.50 $60.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207543 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY EXAM OF PERITONEUM EACH 74190 $57.00 960 $39.90 $28.50 $45.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207352 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY EXAM OF TEAR DUCT EACH 70170 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207725 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY FALLOPIAN TUBE EACH 74742 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207592 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY GUIDE FOR GI TUBE EACH 74340 $65.00 960 $45.50 $32.50 $52.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207618 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY GUIDE GI DILATION EACH 74360 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207600 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY GUIDE INTESTINAL TUBE EACH 74355 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207436 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY OF LOWER SPINE DISK EACH 72295 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207576 PHYSICIAN FEE - INTERVENTIONAL RADIOLOGY PF-X-RAY PANCREAS ENDOSCOPY EACH 74329 $59.00 960 $41.30 $29.50 $47.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99000374 PHYSICIAN FEE - L&D PF-CORDOCENTESIS-(INTRAUTERINE EACH 59012 $590.00 960 $413.00 $295.00 $472.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99000531 PHYSICIAN FEE - L&D PF-DEL PLACENTA-SEPARATE PROC EACH 59414 $266.00 960 $186.20 $133.00 $212.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99000663 PHYSICIAN FEE - L&D PF-FETAL MONITOR/INTERPR ONLY EACH 59051 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99000598 PHYSICIAN FEE - L&D "PF-INDUCED ABORTION, BY D EVAC" EACH 59841 "$1,080.00 " 960 $756.00 $540.00 $864.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99000499 PHYSICIAN FEE - L&D PF-INSERT CERVICAL DILATOR EACH 59200 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99000614 PHYSICIAN FEE - L&D PF-REMOVE CERCLAGE SUTURE EACH 59871 $388.00 960 $271.60 $194.00 $310.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99000515 PHYSICIAN FEE - L&D PF-VAGINAL DELIVERY EACH 59409 "$2,311.00 " 960 "$1,617.70 " "$1,155.50 " "$1,848.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99000549 PHYSICIAN FEE - L&D PF-VBAC DELIVERY EACH 59612 "$2,659.00 " 960 "$1,861.30 " "$1,329.50 " "$2,127.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810526 PHYSICIAN FEE - LAB PF-BLOOD SMEAR INTERPRETATION EACH 85060 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810559 PHYSICIAN FEE - LAB PF-BONE MARROW INTERPRETATION EACH 85097 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800261 PHYSICIAN FEE - LAB PF-CELL ENUMERATION PHYS INTRP EACH 86153 $83.00 960 $58.10 $41.50 $66.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800428 PHYSICIAN FEE - LAB PF-CHCT FOR MAL HYPERTHERMIA EACH 89049 $165.00 960 $115.50 $82.50 $132.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800253 PHYSICIAN FEE - LAB PF-CLOTTING ASSAY WHOLE BLOOD EACH 85396 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810674 PHYSICIAN FEE - LAB PF-COCCIDIOIDOMYCOS SKIN TEST EACH 86490 $193.00 960 $135.10 $96.50 $154.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810740 PHYSICIAN FEE - LAB PF-COLLECT SWEAT FOR TEST EACH 89230 $9.00 960 $6.30 $4.50 $7.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810591 PHYSICIAN FEE - LAB PF-COMPREHENSIVE REIEW DATA EACH 88325 $335.00 960 $234.50 $167.50 $268.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810302 PHYSICIAN FEE - LAB PF-CONSULT PATH REQUIRING PREP EACH 88323 $76.00 960 $53.20 $38.00 $60.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810336 PHYSICIAN FEE - LAB PF-CONSULT PATH SURG CYTO INIT EACH 88333 $82.00 960 $57.40 $41.00 $65.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810344 PHYSICIAN FEE - LAB PF-CONSULT PATH SURG EA ADDL EACH 88334 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810310 PHYSICIAN FEE - LAB PF-CONSULT PATH SURG W/FROZEN EACH 88331 $105.00 960 $73.50 $52.50 $84.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810328 PHYSICIAN FEE - LAB PF-CONSULT PATH SURGERY EA ADD EACH 88332 $64.00 960 $44.80 $32.00 $51.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800444 PHYSICIAN FEE - LAB PF-CONT INTRAOP NEURO MONITOR EACH G0453 $83.00 960 $58.10 $41.50 $66.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800220 PHYSICIAN FEE - LAB PF-CRYSTAL ID LIGHT MICROSCOPY EACH 89060 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810120 PHYSICIAN FEE - LAB PF-CYTO SMEAR OTHER 5+ SLIDES EACH 88162 $96.00 960 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810724 PHYSICIAN FEE - LAB PF-CYTO/MOLECULAR REPORT EACH 88291 $85.00 960 $59.50 $42.50 $68.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810534 PHYSICIAN FEE - LAB PF-CYTOPATH C/V INTERPRET EACH 88141 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810088 PHYSICIAN FEE - LAB PF-CYTOPATH CELLULAR ENHANCE EACH 88112 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810062 PHYSICIAN FEE - LAB PF-CYTOPATH CONCENTRATION EACH 88108 $55.00 960 $38.50 $27.50 $44.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810054 PHYSICIAN FEE - LAB PF-CYTOPATH FLD SIMPLE FILTER EACH 88106 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810005 PHYSICIAN FEE - LAB PF-CYTOPATH FLD SMEAR EACH 88104 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810096 PHYSICIAN FEE - LAB PF-CYTOPATH FORENSIC EACH 88125 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810104 PHYSICIAN FEE - LAB PF-CYTOPATH SMEAR OTHER SOURCE EACH 88160 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810112 PHYSICIAN FEE - LAB PF-CYTOPATH SMEAR OTHER W/PREP EACH 88161 $62.00 960 $43.40 $31.00 $49.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800485 PHYSICIAN FEE - LAB PF-CYTOPATH TBS C/V MANUAL EACH 88164 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800477 PHYSICIAN FEE - LAB PF-CYTOPATHOLOGY PROCEDURE NOS EACH 88199 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800295 PHYSICIAN FEE - LAB PF-CYTP FNA EVAL EA ADDL EACH 88177 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800287 PHYSICIAN FEE - LAB PF-CYTP URINE 3-5 PROBES CMPTR EACH 88121 $118.00 960 $82.60 $59.00 $94.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800279 PHYSICIAN FEE - LAB PF-CYTP URNE 3-5 PROBES EA SPC EACH 88120 $141.00 960 $98.70 $70.50 $112.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800196 PHYSICIAN FEE - LAB PF-DARK FIELD EXAM W/COLLECT EACH 87164 $48.00 960 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810229 PHYSICIAN FEE - LAB PF-DECALCIFICATION EACH 88311 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810377 PHYSICIAN FEE - LAB PF-ELECTRON MICROSCOPY DX EACH 88348 $187.00 960 $130.90 $93.50 $149.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800469 PHYSICIAN FEE - LAB PF-FECAL MICROBIOTA PREP INSTI EACH G0455 $186.00 960 $130.20 $93.00 $148.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800055 PHYSICIAN FEE - LAB PF-FIBRINOLYSINS SCR INT & RPT EACH 85390 $90.00 960 $63.00 $45.00 $72.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810138 PHYSICIAN FEE - LAB PF-FINE NEEDLE EVAL EACH 88172 $56.00 960 $39.20 $28.00 $44.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810146 PHYSICIAN FEE - LAB PF-FINE NEEDLE INTERPRETATION EACH 88173 $169.00 960 $118.30 $84.50 $135.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800329 PHYSICIAN FEE - LAB PF-FISH PER SPEC ADD SGL PROBE EACH 88364 $82.00 960 $57.40 $41.00 $65.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800337 PHYSICIAN FEE - LAB PF-FISH PER SPEC MULTI PROBE EACH 88366 $150.00 960 $105.00 $75.00 $120.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810153 PHYSICIAN FEE - LAB PF-FLOW CYTOM CELL CYCLE/DNA EACH 88182 $93.00 960 $65.10 $46.50 $74.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810690 PHYSICIAN FEE - LAB PF-FLOWCYTOMETRY/ TC 1 MARKER EACH 88184 $198.00 960 $138.60 $99.00 $158.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810583 PHYSICIAN FEE - LAB PF-FLOWCYTOMETRY/READ 16 & > EACH 88189 $210.00 960 $147.00 $105.00 $168.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810567 PHYSICIAN FEE - LAB PF-FLOWCYTOMETRY/READ 2-8 EACH 88187 $90.00 960 $63.00 $45.00 $72.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810716 PHYSICIAN FEE - LAB PF-FLOWCYTOMETRY/READ 9-15 EACH 88188 $155.00 960 $108.50 $77.50 $124.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810708 PHYSICIAN FEE - LAB PF-FLOWCYTOMETRY/TC ADD-ON EACH 88185 $60.00 960 $42.00 $30.00 $48.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800113 PHYSICIAN FEE - LAB PF-FLUOR AB TTR EACH 86256 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800071 PHYSICIAN FEE - LAB PF-FLUORESCENT ANTIBODY SCREEN EACH 86255 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810179 PHYSICIAN FEE - LAB PF-GROSS & MICRO LEVEL II EACH 88302 $18.00 960 $12.60 $9.00 $14.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810187 PHYSICIAN FEE - LAB PF-GROSS & MICRO LEVEL III EACH 88304 $29.00 960 $20.30 $14.50 $23.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810195 PHYSICIAN FEE - LAB PF-GROSS & MICRO LEVEL IV EACH 88305 $91.00 960 $63.70 $45.50 $72.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810203 PHYSICIAN FEE - LAB PF-GROSS & MICRO LEVEL V EACH 88307 $199.00 960 $139.30 $99.50 $159.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810211 PHYSICIAN FEE - LAB PF-GROSS & MICRO LEVEL VI EACH 88309 $351.00 960 $245.70 $175.50 $280.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810161 PHYSICIAN FEE - LAB PF-GROSS ONLY LEVEL I EACH 88300 $12.00 960 $8.40 $6.00 $9.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800006 PHYSICIAN FEE - LAB PF-HEMOGLOBIN ELECTROPHORESIS EACH 83020 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810682 PHYSICIAN FEE - LAB PF-HISTOPLASMOSIS SKIN TEST EACH 86510 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810351 PHYSICIAN FEE - LAB PF-IF DIRECT AB EA EACH 88346 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800212 PHYSICIAN FEE - LAB PF-IF INDIRECT CENTROMERE EACH 88350 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800162 PHYSICIAN FEE - LAB PF-IMMUNOELECTROPHORESIS CROSS EACH 86327 $54.00 960 $37.80 $27.00 $43.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800147 PHYSICIAN FEE - LAB PF-IMMUNOELECTROPHORESIS OTHER EACH 86325 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800121 PHYSICIAN FEE - LAB PF-IMMUNOELECTROPHORESIS SERUM EACH 86320 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800170 PHYSICIAN FEE - LAB PF-IMMUNOFIX ELECTRO SERUM EACH 86334 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800188 PHYSICIAN FEE - LAB PF-IMMUNOFIXATION ELECTR OTHER EACH 86335 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800303 PHYSICIAN FEE - LAB PF-IMMUNOHISTO ANTIBODY SLIDE EACH 88341 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810609 PHYSICIAN FEE - LAB PF-IMMUNOHISTO ANTIBODY SLIDE EACH 88344 $93.00 960 $65.10 $46.50 $74.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810617 PHYSICIAN FEE - LAB PF-IMMUNOHISTO ANTIBODY STAIN EACH 88342 $85.00 960 $59.50 $42.50 $68.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810450 PHYSICIAN FEE - LAB PF-IN SITU HYBRIDIZATION(FISH) EACH 88365 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800352 PHYSICIAN FEE - LAB PF-M/PHMTRC ALYS ADD SGL PROBE EACH 88373 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800386 PHYSICIAN FEE - LAB PF-M/PHMTRC ALYS ISHQUANT/SEMQ EACH 88377 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800360 PHYSICIAN FEE - LAB PF-M/PHMTRC ALYS MULTI PROBE EACH 88374 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800345 PHYSICIAN FEE - LAB PF-M/PHMTRC ALYSISHQUANT/SEMIQ EACH 88369 $82.00 960 $57.40 $41.00 $65.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800451 PHYSICIAN FEE - LAB PF-MD DOCUMENT VISIT BY NPP EACH G0454 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800394 PHYSICIAN FEE - LAB PF-MICRODISSECTION LASER EACH 88380 $127.00 960 $88.90 $63.50 $101.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810500 PHYSICIAN FEE - LAB PF-MICRODISSECTION MANUAL EACH 88381 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810575 PHYSICIAN FEE - LAB PF-MICROSLIDE CONSULTATION EACH 88321 $209.00 960 $146.30 $104.50 $167.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800436 PHYSICIAN FEE - LAB PF-MOLECULAR PATHOLOGY INTERPR EACH G0452 $10.00 960 $7.00 $5.00 $8.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810435 PHYSICIAN FEE - LAB PF-MORPHO ANLYS COMPUTER ASST EACH 88361 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810468 PHYSICIAN FEE - LAB PF-MORPHO ANLYS INSITU HYBRID EACH 88367 $81.00 960 $56.70 $40.50 $64.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810401 PHYSICIAN FEE - LAB PF-MORPHO ANLYS NERVE EACH 88356 $296.00 960 $207.20 $148.00 $236.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810393 PHYSICIAN FEE - LAB PF-MORPHO ANLYS SKELETAL MUSC EACH 88355 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810419 PHYSICIAN FEE - LAB PF-MORPHO ANLYS TUMR EACH 88358 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810427 PHYSICIAN FEE - LAB PF-MORPHO ANLYS TUMR MANUAL EACH 88360 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810476 PHYSICIAN FEE - LAB PF-MORPHO INSITU HYBRID MAN EACH 88368 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810443 PHYSICIAN FEE - LAB PF-NERVE TEASING PREPARATIONS EACH 88362 $271.00 960 $189.70 $135.50 $216.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800378 PHYSICIAN FEE - LAB PF-OPTICAL ENDOMICROSCPY INTRP EACH 88375 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810542 PHYSICIAN FEE - LAB PF-PATH CONSULT INTROP EACH 88329 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810641 PHYSICIAN FEE - LAB PF-PHYS BLOOD BANK SERV AUTHRJ EACH 86079 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810633 PHYSICIAN FEE - LAB PF-PHYS BLOOD BANK SERV REACTJ EACH 86078 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810625 PHYSICIAN FEE - LAB PF-PHYS BLOOD BANK SERV XMATCH EACH 86077 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800063 PHYSICIAN FEE - LAB PF-PLATELET AGGREGATION EA EACH 85576 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810492 PHYSICIAN FEE - LAB PF-PROTEIN ANLYS W/BAND PROBE EACH 88372 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810484 PHYSICIAN FEE - LAB PF-PROTEIN ANLYS WESTERN BLOT EACH 88371 $48.00 960 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800014 PHYSICIAN FEE - LAB PF-PROTEIN ELECTROPHORES SERUM EACH 84165 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800022 PHYSICIAN FEE - LAB PF-PROTEIN ELECTROPHORS UR CSF EACH 84166 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800030 PHYSICIAN FEE - LAB PF-PROTEIN WESTERN BLOT EACH 84181 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800048 PHYSICIAN FEE - LAB PF-PROTEIN WESTERN BLOT BND ID EACH 84182 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810658 PHYSICIAN FEE - LAB PF-SKIN TEST CANDIDA EACH 86485 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810666 PHYSICIAN FEE - LAB PF-SKIN TEST NOS ANTIGEN EACH 86486 $17.00 960 $11.90 $8.50 $13.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810260 PHYSICIAN FEE - LAB PF-SPECIAL HISTOS TAIN W/FROZ EACH 88314 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810245 PHYSICIAN FEE - LAB PF-SPECIAL STAIN GROUP 1 EACH 88312 $65.00 960 $45.50 $32.50 $52.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810278 PHYSICIAN FEE - LAB PF-SPECIAL STAIN GROUP III EACH 88319 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800204 PHYSICIAN FEE - LAB PF-SPECIAL STAIN W/BODS/PARS EACH 87207 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810252 PHYSICIAN FEE - LAB PF-SPECIAL STAINS GR 2 (W/S&I) EACH 88313 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810732 PHYSICIAN FEE - LAB PF-SPUTUM SPECIMEN COLLECTION EACH 89220 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98810518 PHYSICIAN FEE - LAB PF-TB INTRADERMAL TEST EACH 86580 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800410 PHYSICIAN FEE - LAB PF-TISS EX MOLECUL STUDY ADDON EACH 88388 $35.00 960 $24.50 $17.50 $28.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800402 PHYSICIAN FEE - LAB PF-TISS EXAM MOLECULAR STUDY EACH 88387 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98800311 PHYSICIAN FEE - LAB PF-XM ARCHIVE TISSUE MOLEC ANL EACH 88363 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600499 PHYSICIAN FEE - MAMMOGRAPHY PF-BIOPHYSICAL PROF (W NST) EACH 76818 $125.00 960 $87.50 $62.50 $100.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600507 PHYSICIAN FEE - MAMMOGRAPHY PF-BIOPHYSICAL PROF (W/ NST) EACH 76819 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600069 PHYSICIAN FEE - MAMMOGRAPHY PF-BREAST TOMOSYNTHESIS - LEFT EACH 77061 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600077 PHYSICIAN FEE - MAMMOGRAPHY PF-BREAST TOMOSYNTHESIS RIGHT EACH 77061 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600085 PHYSICIAN FEE - MAMMOGRAPHY PF-BREAST TOMOSYNTHESIS-BI EACH 77062 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96601042 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 1ST LES MRI BI EACH 19085 $463.00 960 $324.10 $231.50 $370.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96601018 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 1ST LES MRI LT EACH 19085 $463.00 960 $324.10 $231.50 $370.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96601034 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 1ST LES MRI RT EACH 19085 $463.00 960 $324.10 $231.50 $370.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600838 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 1ST LES STEREO BI EACH 19081 $424.00 960 $296.80 $212.00 $339.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600804 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 1ST LES STEREO LT EACH 19081 $424.00 960 $296.80 $212.00 $339.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600820 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 1ST LES STEREO RT EACH 19081 $424.00 960 $296.80 $212.00 $339.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600937 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 1ST LES US BI EACH 19083 $403.00 960 $282.10 $201.50 $322.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600911 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 1ST LES US LT EACH 19083 $403.00 960 $282.10 $201.50 $322.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600929 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 1ST LES US RT EACH 19083 $403.00 960 $282.10 $201.50 $322.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96601059 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 2ND LES MRI 1 EACH 19086 $231.00 960 $161.70 $115.50 $184.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96601067 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 2ND LES MRI 2 EACH 19086 $231.00 960 $161.70 $115.50 $184.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96601075 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 2ND LES MRI BI EACH 19086 $231.00 960 $161.70 $115.50 $184.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600945 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 2ND LES US 1 EACH 19084 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600960 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 2ND LES US 1 EACH 19084 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600978 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 2ND LES US BI EACH 19084 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600879 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 3RD LES STEREO 1 EACH 19082 $213.00 960 $149.10 $106.50 $170.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600895 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 3RD LES STEREO 1 EACH 19082 $213.00 960 $149.10 $106.50 $170.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600903 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST 3RD LES STEREO BI EACH 19082 $213.00 960 $149.10 $106.50 $170.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96601141 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST NDL 1 LES BI EACH 19100 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96601125 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST NDL 1 LES LT EACH 19100 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96601133 PHYSICIAN FEE - MAMMOGRAPHY PF-BX BREAST NDL 1 LES RT EACH 19100 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600200 PHYSICIAN FEE - MAMMOGRAPHY PF-DIAGNOSISTIC MAMMOGRAM UNI EACH 77065 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600523 PHYSICIAN FEE - MAMMOGRAPHY PF-DOPPLER VELOCIMETRY - MCA EACH 76821 $84.00 960 $58.80 $42.00 $67.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600515 PHYSICIAN FEE - MAMMOGRAPHY PF-DOPPLER VELOCIMETRY - UA EACH 76820 $55.00 960 $38.50 $27.50 $44.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600705 PHYSICIAN FEE - MAMMOGRAPHY PF-GI ENDOSCOPIC ULTRASOUND EACH 76975 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600051 PHYSICIAN FEE - MAMMOGRAPHY PF-MAMM DUCTOGRAM MULTIPLE S&I EACH 77054 $54.00 960 $37.80 $27.00 $43.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600036 PHYSICIAN FEE - MAMMOGRAPHY PF-MAMMARY DUCTOGRAM SGL S&I EACH 77053 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600143 PHYSICIAN FEE - MAMMOGRAPHY PF-MAMMO SCREENING EACH 77067 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600101 PHYSICIAN FEE - MAMMOGRAPHY PF-MAMMOGRAM DIAGNOSTIC BILAT EACH 77066 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600440 PHYSICIAN FEE - MAMMOGRAPHY PF-NUCHAL TRANLUCENCY ADD EACH 76814 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600432 PHYSICIAN FEE - MAMMOGRAPHY PF-NUCHAL TRANLUCENCY SGL EACH 76813 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600267 PHYSICIAN FEE - MAMMOGRAPHY PF-OPHTH US B & QUANT A EACH 76510 $78.00 960 $54.60 $39.00 $62.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600556 PHYSICIAN FEE - MAMMOGRAPHY PF-SALINE INFUSED SONOGRAM EACH 76831 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600093 PHYSICIAN FEE - MAMMOGRAPHY PF-SCREENING BREAST TOMOSYN-BI EACH 77063 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600002 PHYSICIAN FEE - MAMMOGRAPHY PF-ULTRASOUND BREAST COMPLETE EACH 76641 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600010 PHYSICIAN FEE - MAMMOGRAPHY PF-ULTRASOUND BREAST LIMITED EACH 76642 $83.00 960 $58.10 $41.50 $66.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600473 PHYSICIAN FEE - MAMMOGRAPHY PF-US ABD F/UP - PER FETUS EACH 76816 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600291 PHYSICIAN FEE - MAMMOGRAPHY PF-US ABDOMEN COMPLETE EACH 76700 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600713 PHYSICIAN FEE - MAMMOGRAPHY PF-US BONE DENSITY MEASURE EACH 76977 $8.00 960 $5.60 $4.00 $6.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600283 PHYSICIAN FEE - MAMMOGRAPHY PF-US CHEST EACH 76604 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600242 PHYSICIAN FEE - MAMMOGRAPHY PF-US ENCEPHALOGRAM EACH 76506 $82.00 960 $57.40 $41.00 $65.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600622 PHYSICIAN FEE - MAMMOGRAPHY PF-US EXTREMITY NONVASC COMPL EACH 76881 $29.00 960 $20.30 $14.50 $23.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600630 PHYSICIAN FEE - MAMMOGRAPHY PF-US EXTREMITY NONVASC LTD EACH 76882 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600663 PHYSICIAN FEE - MAMMOGRAPHY PF-US GUIDANCE FOR CVS (S & I) EACH 76945 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600689 PHYSICIAN FEE - MAMMOGRAPHY PF-US GUIDE FOR AMNIO (S & I) EACH 76946 $40.00 960 $28.00 $20.00 $32.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600648 PHYSICIAN FEE - MAMMOGRAPHY PF-US HIPS INFANT DYNAMIC EACH 76885 $90.00 960 $63.00 $45.00 $72.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96600655 PHYSICIAN FEE 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Payable Non Payable 96900873 PHYSICIAN FEE - MRI PF-MRA LWR EXT W&WO CON RT EACH 73725 $217.00 960 $151.90 $108.50 $173.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900105 PHYSICIAN FEE - MRI PF-MRA NECK W&W/O CON EACH 70549 $216.00 960 $151.20 $108.00 $172.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900097 PHYSICIAN FEE - MRI PF-MRA NECK W/CON EACH 70548 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900089 PHYSICIAN FEE - MRI PF-MRA NECK W/O CON EACH 70547 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900378 PHYSICIAN FEE - MRI PF-MRA PELVIS EACH 72198 $215.00 960 $150.50 $107.50 $172.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900329 PHYSICIAN FEE - MRI PF-MRA SPINE W/ OR W/O CONT EACH 72159 $217.00 960 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Payable Non Payable Non Payable 96900121 PHYSICIAN FEE - MRI PF-MRI BRAIN W/CON EACH 70552 $215.00 960 $150.50 $107.50 $172.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96901194 PHYSICIAN FEE - MRI PF-MRI BRAIN W/DYE EACH 70558 $423.00 960 $296.10 $211.50 $338.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96901202 PHYSICIAN FEE - MRI PF-MRI BRAIN W/O & W/DYE EACH 70559 $408.00 960 $285.60 $204.00 $326.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900113 PHYSICIAN FEE - MRI PF-MRI BRAIN W/O CON EACH 70551 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96901178 PHYSICIAN FEE - MRI PF-MRI BRAIN W/O DYE EACH 70557 $384.00 960 $268.80 $192.00 $307.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96901525 PHYSICIAN FEE - MRI PF-MRI BREAST W/O CONTRAST BI EACH 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Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96901079 PHYSICIAN FEE - MRI PF-MRI CARD W/O&W CON STRESS EACH 75563 $351.00 960 $245.70 $175.50 $280.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96901053 PHYSICIAN FEE - MRI PF-MRI CARDIAC W/O CONT STRESS EACH 75559 $343.00 960 $240.10 $171.50 $274.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96901038 PHYSICIAN FEE - MRI PF-MRI CARDIAC W/O CONTRAST EACH 75557 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96901061 PHYSICIAN FEE - MRI PF-MRI CARDIAC W/O&W CONTRAST EACH 75561 $308.00 960 $215.60 $154.00 $246.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900295 PHYSICIAN FEE - MRI PF-MRI CERVICAL SP W&WO CON EACH 72156 $277.00 960 $193.90 $138.50 $221.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900220 PHYSICIAN FEE - MRI PF-MRI CERVICAL SP WO CONTRAST EACH 72141 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900238 PHYSICIAN FEE - MRI PF-MRI CERVICAL SPINE W/CON EACH 72142 $217.00 960 $151.90 $108.50 $173.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900170 PHYSICIAN FEE - MRI PF-MRI CHEST W&W/O CONTRAST EACH 71552 $273.00 960 $191.10 $136.50 $218.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900162 PHYSICIAN FEE - MRI PF-MRI CHEST W/CONTRAST EACH 71551 $209.00 960 $146.30 $104.50 $167.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900154 PHYSICIAN FEE - MRI PF-MRI CHEST W/O CONTRAST EACH 71550 $177.00 960 $123.90 $88.50 $141.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900816 PHYSICIAN FEE - MRI 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Payable Non Payable Non Payable Non Payable Non Payable 96900733 PHYSICIAN FEE - MRI PF-MRI LWR EXT W&W/O CON RT EACH 73720 $259.00 960 $181.30 $129.50 $207.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900709 PHYSICIAN FEE - MRI PF-MRI LWR EXT W/CON BIL EACH 73719 $195.00 960 $136.50 $97.50 $156.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900717 PHYSICIAN FEE - MRI PF-MRI LWR EXT W/CON LT EACH 73719 $195.00 960 $136.50 $97.50 $156.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900683 PHYSICIAN FEE - MRI PF-MRI LWR EXT W/CON RT EACH 73719 $195.00 960 $136.50 $97.50 $156.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900667 PHYSICIAN FEE - MRI PF-MRI LWR EXT W/O CON BIL EACH 73718 $163.00 960 $114.10 $81.50 $130.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900675 PHYSICIAN 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Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900600 PHYSICIAN FEE - MRI PF-MRI UP EXTREMTY JT W&WO BIL EACH 73223 $260.00 960 $182.00 $130.00 $208.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900568 PHYSICIAN FEE - MRI PF-MRI UPPER EXT JT W/CON LT EACH 73222 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900543 PHYSICIAN FEE - MRI PF-MRI UPPER EXT JT W/CON RT EACH 73222 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900535 PHYSICIAN FEE - MRI PF-MRI UPR EXT JNT W/O CON LT EACH 73221 $164.00 960 $114.80 $82.00 $131.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900519 PHYSICIAN FEE - MRI PF-MRI UPR EXT JNT W/O CON RT EACH 73221 $164.00 960 $114.80 $82.00 $131.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96900527 PHYSICIAN FEE - MRI PF-MRI UPR EXT JT W/O CON BI EACH 73221 $164.00 960 $114.80 $82.00 $131.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400767 PHYSICIAN FEE - NUCLEAR MEDICINE PF-ACUTE VENOUS THROMBUS IMAGE EACH 78456 $116.00 960 $81.20 $58.00 $92.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400171 PHYSICIAN FEE - NUCLEAR MEDICINE PF-ADRENAL CORTEX-MEDULLA IMG EACH 78075 $90.00 960 $63.00 $45.00 $72.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400270 PHYSICIAN FEE - NUCLEAR MEDICINE PF-BLOOD VOLUME EACH 78122 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400650 PHYSICIAN FEE - NUCLEAR MEDICINE PF-BONE IMAGING 3 PHASE EACH 78315 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400999 PHYSICIAN FEE - NUCLEAR MEDICINE PF-BRAIN IMAGE < 4 VIEWS EACH 78600 $53.00 960 $37.10 $26.50 $42.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400692 PHYSICIAN FEE - NUCLEAR MEDICINE PF-CARDIAC SHUNT IMAGING EACH 78428 $91.00 960 $63.70 $45.50 $72.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401112 PHYSICIAN FEE - NUCLEAR MEDICINE PF-CSF LEAKAGE IMAGING EACH 78650 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401088 PHYSICIAN FEE - NUCLEAR MEDICINE PF-CSF SHUNT EVALUATION EACH 78645 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401070 PHYSICIAN FEE - NUCLEAR MEDICINE PF-CSF VENTRICULOGRAPHY EACH 78635 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400007 PHYSICIAN FEE - NUCLEAR MEDICINE PF-DEXA BONE DENSITY AXIAL EACH 77080 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400031 PHYSICIAN FEE - NUCLEAR MEDICINE PF-DEXA W/VERTEBRAL FRACT ASSM EACH 77085 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400023 PHYSICIAN FEE - NUCLEAR MEDICINE PF-DXA BONE DENSITY/PERIPHERAL EACH 77081 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400494 PHYSICIAN FEE - NUCLEAR MEDICINE PF-ESOPHAGEAL MOTILITY STUDY EACH 78258 $84.00 960 $58.80 $42.00 $67.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400049 PHYSICIAN FEE - NUCLEAR MEDICINE PF-FRACTURE ASSESSMENT VIA DXA EACH 77086 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400502 PHYSICIAN FEE - NUCLEAR MEDICINE PF-GASTRIC MUCOSA IMAGING EACH 78261 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400510 PHYSICIAN FEE - NUCLEAR MEDICINE PF-GASTROESOPHAGEAL REFLUX EACH 78262 $82.00 960 $57.40 $41.00 $65.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400858 PHYSICIAN FEE - NUCLEAR MEDICINE PF-GATED HEART MULTIPLE EACH 78473 $171.00 960 $119.70 $85.50 $136.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400841 PHYSICIAN FEE - NUCLEAR MEDICINE PF-GATED HEART PLANAR SINGLE EACH 78472 $116.00 960 $81.20 $58.00 $92.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400585 PHYSICIAN FEE - NUCLEAR MEDICINE PF-GI PROTEIN LOSS EXAM EACH 78282 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400924 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEART FIRST PASS ADD-ON EACH 78496 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400874 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEART FIRST PASS MULTIPLE EACH 78483 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400866 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEART FIRST PASS SINGLE EACH 78481 $116.00 960 $81.20 $58.00 $92.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400916 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEART IMAGE SPECT EACH 78494 $139.00 960 $97.30 $69.50 $111.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400809 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEART INFARCT IMAGE EACH 78466 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400833 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEART INFARCT IMAGE (3D) EACH 78469 $107.00 960 $74.90 $53.50 $85.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400817 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEART INFARCT IMAGE (EF) EACH 78468 $94.00 960 $65.80 $47.00 $75.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401393 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEMATOPOIETIC NUCLEAR TX EACH 79403 $257.00 960 $179.90 $128.50 $205.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400445 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEPATOBIL SYST IMAGE W/DRUG EACH 78227 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400437 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HEPATOBIL SYST W/O DRUG EACH 78226 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400718 PHYSICIAN FEE - NUCLEAR MEDICINE PF-HT MUSCLE IMAGE SPECT SING EACH 78451 $161.00 960 $112.70 $80.50 $128.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401203 PHYSICIAN FEE - NUCLEAR MEDICINE PF-KIDNEY FUNCTION STUDY EACH 78725 $43.00 960 $30.10 $21.50 $34.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400601 PHYSICIAN FEE - NUCLEAR MEDICINE PF-LEVEEN/SHUNT PATENCY EXAM EACH 78291 $107.00 960 $74.90 $53.50 $85.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400361 PHYSICIAN FEE - NUCLEAR MEDICINE PF-LIVER IMAGING EACH 78201 $51.00 960 $35.70 $25.50 $40.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400981 PHYSICIAN FEE - NUCLEAR MEDICINE PF-LUNG PERF & VENT DIFF EACH 78598 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400973 PHYSICIAN FEE - NUCLEAR MEDICINE PF-LUNG PERFUSION DIFFERENTIAL EACH 78597 $85.00 960 $59.50 $42.50 $68.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400957 PHYSICIAN FEE - NUCLEAR MEDICINE PF-LUNG VENT & PERFUS IMAGING EACH 78582 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400932 PHYSICIAN FEE - NUCLEAR MEDICINE PF-LUNG VENTILATION IMAGING EACH 78579 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400627 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BONE LIMITED EACH 78300 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400189 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BONE MARROW LIMITED EACH 78102 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400205 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BONE MARROW MULTIPLE EACH 78103 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400213 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BONE MARROW WHOLE BODY EACH 78104 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400635 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BONE MULTIPLE AREAS EACH 78305 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400643 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BONE WHOLE BODY EACH 78306 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401013 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BRAIN MIN 4 STATIC VIEWS EACH 78605 $65.00 960 $45.50 $32.50 $52.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401054 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BRAIN VASCULAR FLOW ONLY EACH 78610 $35.00 960 $24.50 $17.50 $28.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401005 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BRAIN W FLOW < 4V STATIC EACH 78601 $60.00 960 $42.00 $30.00 $48.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401021 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM BRAIN W FLOW 4+V STATIC EACH 78606 $76.00 960 $53.20 $38.00 $60.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401062 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM CSF CISTERNOGRAM EACH 78630 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400528 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM GASTRIC EMPTYING EACH 78264 $94.00 960 $65.80 $47.00 $75.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400577 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM GI BLOOD LOSS EACH 78278 $118.00 960 $82.60 $59.00 $94.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400726 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM HRT MSC IMAGE SPECT MULT EACH 78452 $190.00 960 $133.00 $95.00 $152.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400742 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM HRT MUSC IMAGE EACH 78454 $161.00 960 $112.70 $80.50 $128.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400734 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM HRT MUSCLE IMAGE EACH 78453 $114.00 960 $79.80 $57.00 $91.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400593 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM INTESTINE MUCOSA/MECKELS EACH 78290 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401187 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM KIDNEY F&F MULT W/WO RX EACH 78709 $164.00 960 $114.80 $82.00 $131.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401161 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM KIDNEY FLO&FUNC SGL W RX EACH 78708 $141.00 960 $98.70 $70.50 $112.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401138 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM KIDNEY SCAN MORPHOLOGY EACH 78700 $53.00 960 $37.10 $26.50 $42.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401146 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM KIDNEY SCAN W/FLOW EACH 78701 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401153 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM KIDNEY SCAN W/FLOW&FUNCT EACH 78707 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400411 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM LIVER & SPLEEN STATIC EACH 78215 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400379 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM LIVER W/ VASCULAR FLOW EACH 78202 $59.00 960 $41.30 $29.50 $47.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400429 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM LIVER&SPLEEN W/VASC FLOW EACH 78216 $65.00 960 $45.50 $32.50 $52.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400353 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM LYMPH SYSTEM EACH 78195 $141.00 960 $98.70 $70.50 $112.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400148 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM PARATHYROID EACH 78070 $96.00 960 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400940 PHYSICIAN FEE - NUCLEAR MEDICINE PF-NM PULMONARY PERFUSION PART EACH 78580 $88.00 960 $61.60 $44.00 $70.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 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NUCLEAR MEDICINE PF-NUCLR RX INTERSTIT COLLOID EACH 79300 $157.00 960 $109.90 $78.50 $125.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400155 PHYSICIAN FEE - NUCLEAR MEDICINE PF-PARATHYROID PLANAR (SPECT) EACH 78071 $142.00 960 $99.40 $71.00 $113.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400163 PHYSICIAN FEE - NUCLEAR MEDICINE PF-PARATHYROID PLANR W/CT EACH 78072 $185.00 960 $129.50 $92.50 $148.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400791 PHYSICIAN FEE - NUCLEAR MEDICINE PF-PET MYOCARD METABOLIC EVAL EACH 78459 $183.00 960 $128.10 $91.50 $146.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400908 PHYSICIAN FEE - NUCLEAR MEDICINE PF-PET MYOCARD PERF MULTI ST EACH 78492 $211.00 960 $147.70 $105.50 $168.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400882 PHYSICIAN FEE - NUCLEAR MEDICINE PF-PET MYOCARD PERF SGL STUDY EACH 78491 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400239 PHYSICIAN FEE - NUCLEAR MEDICINE PF-PLASMA VOLUME MULTIPLE EACH 78111 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400221 PHYSICIAN FEE - NUCLEAR MEDICINE PF-PLASMA VOLUME SINGLE EACH 78110 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400346 PHYSICIAN FEE - NUCLEAR MEDICINE PF-PLATELET SURVIVAL EACH 78191 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400254 PHYSICIAN FEE - NUCLEAR MEDICINE PF-RED CELL MASS MULTIPLE EACH 78121 $33.00 960 $23.10 $16.50 $26.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400247 PHYSICIAN FEE - NUCLEAR MEDICINE PF-RED CELL MASS SINGLE EACH 78120 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400304 PHYSICIAN FEE - NUCLEAR MEDICINE PF-RED CELL SEQUESTRATION EACH 78140 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400288 PHYSICIAN FEE - NUCLEAR MEDICINE PF-RED CELL SURVIVAL STUDY EACH 78130 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400486 PHYSICIAN FEE - NUCLEAR MEDICINE PF-SALIVARY GLAND FUNCTION EX EACH 78232 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400452 PHYSICIAN FEE - NUCLEAR MEDICINE PF-SALIVARY GLAND IMAGING EACH 78230 $54.00 960 $37.80 $27.00 $43.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400460 PHYSICIAN FEE - NUCLEAR MEDICINE PF-SERIAL SALIVARY IMAGING EACH 78231 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400072 PHYSICIAN FEE - NUCLEAR MEDICINE PF-THYROID IMAGING EACH 78013 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400080 PHYSICIAN FEE - NUCLEAR MEDICINE PF-THYROID IMAGING W/UPTAKE(S) EACH 78014 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400098 PHYSICIAN FEE - NUCLEAR MEDICINE PF-THYROID MET IMAGING EACH 78015 $81.00 960 $56.70 $40.50 $64.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400106 PHYSICIAN FEE - NUCLEAR MEDICINE PF-THYROID MET IMAGING/STUDIES EACH 78016 $81.00 960 $56.70 $40.50 $64.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400130 PHYSICIAN FEE - NUCLEAR MEDICINE PF-THYROID MET UPTAKE EACH 78020 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400064 PHYSICIAN FEE - NUCLEAR MEDICINE PF-THYROID UPTAKE EACH 78012 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401229 PHYSICIAN FEE - NUCLEAR MEDICINE PF-URETERAL REFLUX STUDY EACH 78740 $67.00 960 $46.90 $33.50 $53.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96401211 PHYSICIAN FEE - NUCLEAR MEDICINE PF-URINARY BLADDER RETENTION EACH 78730 $19.00 960 $13.30 $9.50 $15.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400700 PHYSICIAN FEE - NUCLEAR MEDICINE PF-VASCULAR FLOW IMAGING EACH 78445 $64.00 960 $44.80 $32.00 $51.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400783 PHYSICIAN FEE - NUCLEAR MEDICINE PF-VENOGRAM - BILATERAL EACH 78458 $110.00 960 $77.00 $55.00 $88.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96400775 PHYSICIAN FEE - NUCLEAR MEDICINE PF-VENOGRAM - UNILATERAL EACH 78457 $100.00 960 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100275 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT AQUATIC THERAPY/EXERCISE EACH 97113 $93.00 960 $65.10 $46.50 $74.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100440 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT ASSISTIVE TECH ASSESS EACH 97755 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100499 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT CHIROPRACT MANJ 1-2 REG EACH 98940 $55.00 960 $38.50 $27.50 $44.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100507 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT CHIROPRACT MANJ 3-4 REG EACH 98941 $84.00 960 $58.80 $42.00 $67.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100515 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT CHIROPRACTIC MANJ 5 REG EACH 98942 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100374 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT COMMUNITY/WORK REINTEGR EACH 97537 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100218 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT CONTRAST BATH THERAPY EACH 97034 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100119 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT DEVEL SCREENING-CLINIC EACH 96110 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100556 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT ELEC STIM NOT WOUND EACH G0283 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100531 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT ELEC STIM UNATT PRESS EACH G0281 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100200 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT ELECTRIC CURRENT THERAPY EACH 97033 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100184 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT ELECTRICAL STIMULATION EACH 97032 $37.00 960 $25.90 $18.50 $29.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100028 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT EVAL - HIGH COMPLEXITY EACH 97171 $298.00 960 $208.60 $149.00 $238.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100002 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT EVAL - LOW COMPLEXITY EACH 97169 $218.00 960 $152.60 $109.00 $174.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100010 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT EVAL - MODERATE COMPLEX EACH 97170 $258.00 960 $180.60 $129.00 $206.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100283 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT GAIT TRAINING THERAPY EACH 97116 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100317 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT GROUP THERAPEUT PROC EACH 97150 $46.00 960 $32.20 $23.00 $36.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100234 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT HYDROTHERAPY EACH 97036 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100424 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT LOW FREQ NON-THERM US EACH 97610 $45.00 960 $31.50 $22.50 $36.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100309 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT MANUAL THERAPY 1/> REG EACH 97140 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100291 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT MASSAGE THERAPY EACH 97124 $77.00 960 $53.90 $38.50 $61.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100143 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT MECHANICAL TRACTION TX EACH 97012 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100259 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT NEUROMUSCULR REEDUCATION EACH 97112 $85.00 960 $59.50 $42.50 $68.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100457 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT ORTHOTIC MGMT/TRAINING EACH 97760 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100168 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT PARAFFIN BATH THERAPY EACH 97018 $15.00 960 $10.50 $7.50 $12.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100432 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT PHYSICAL PERF TEST EACH 97750 $86.00 960 $60.20 $43.00 $68.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100465 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT PROSTHETIC TRAINING EACH 97761 $105.00 960 $73.50 $52.50 $84.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100093 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT RANGE OF MOTION EXT/TRNK EACH 95851 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100101 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT RANGE OF MOTION HAND EACH 95852 $15.00 960 $10.50 $7.50 $12.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100036 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT RE-EVALUATION EACH 97172 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100366 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT SELF CARE MNGMENT TRAIN EACH 97535 $83.00 960 $58.10 $41.50 $66.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100523 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT SELF-MGMT ED/TRAIN 1 PT EACH 98960 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100358 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT SENSORY INTEGRATION EACH 97533 $157.00 960 $109.90 $78.50 $125.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100325 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT THERAPEUTIC ACTIVITIES EACH 97530 $93.00 960 $65.10 $46.50 $74.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100242 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT THERAPEUTIC EXERCISES EACH 97110 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100226 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT ULTRASOUND THERAPY EACH 97035 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100150 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT VASOPNEUMATIC DEVICE TX EACH 97016 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100382 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT WHEELCHAIR MNGMENT TRAIN EACH 97542 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97100176 PHYSICIAN FEE - OCCUPATIONAL THERAPY PF-OT/PT WHIRLPOOL THERAPY EACH 97022 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904056 PHYSICIAN FEE - OPHTHALMOLOGY PF-A-SCAN BIOMETRY EACH 76516 $56.00 960 $39.20 $28.00 $44.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904064 PHYSICIAN FEE - OPHTHALMOLOGY PF-A-SCAN W/IOL CALCULATION EACH 76519 $75.00 960 $52.50 $37.50 $60.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902779 PHYSICIAN FEE - OPHTHALMOLOGY PF-BIOPSY OF CORNEA EACH 65410 $263.00 960 $184.10 $131.50 $210.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904221 PHYSICIAN FEE - OPHTHALMOLOGY PF-CMPTR OPH DX IMG ANT SEG EACH 92132 $40.00 960 $28.00 $20.00 $32.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904395 PHYSICIAN FEE - OPHTHALMOLOGY PF-COLOR VISION TESTING EACH 92283 $22.00 960 $15.40 $11.00 $17.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904114 PHYSICIAN FEE - OPHTHALMOLOGY PF-COMPUTER CORNEAL TOPOGRP EACH 92025 $45.00 960 $31.50 $22.50 $36.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904155 PHYSICIAN FEE - OPHTHALMOLOGY PF-CONTACT LENS FITTING TX EACH 92071 $81.00 960 $56.70 $40.50 $64.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904163 PHYSICIAN FEE - OPHTHALMOLOGY PF-CONTACT LENS KERATOCON EACH 92072 $230.00 960 $161.00 $115.00 $184.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904262 PHYSICIAN FEE - OPHTHALMOLOGY PF-CORNEAL HYSTERESIS DETER EACH 92145 $15.00 960 $10.50 $7.50 $12.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902803 PHYSICIAN FEE - OPHTHALMOLOGY PF-CORNEAL SMEAR EACH 65430 $259.00 960 $181.30 $129.50 $207.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903470 PHYSICIAN FEE - OPHTHALMOLOGY PF-CORRECT TRICHIASIS FORCP EACH 67820 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903496 PHYSICIAN FEE - OPHTHALMOLOGY PF-CORRECT TRICHIASIS W/GFT EACH 67835 "$1,128.00 " 960 $789.60 $564.00 $902.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903033 PHYSICIAN FEE - OPHTHALMOLOGY PF-DEST CILIARY BODY CRYOTH EACH 66720 "$1,053.00 " 960 $737.10 $526.50 $842.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903041 PHYSICIAN FEE - OPHTHALMOLOGY PF-DEST CILIARYCYCLODIALYS EACH 66740 "$1,002.00 " 960 $701.40 $501.00 $801.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903249 PHYSICIAN FEE - OPHTHALMOLOGY PF-DEST LES RETINAL PHOTOCO EACH 67210 "$1,273.00 " 960 $891.10 $636.50 "$1,018.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903223 PHYSICIAN FEE - OPHTHALMOLOGY PF-DEST LES RETINL CRYO/DIA EACH 67208 "$1,473.00 " 960 "$1,031.10 " $736.50 "$1,178.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903272 PHYSICIAN FEE - OPHTHALMOLOGY PF-DESTRUCT EXT/PROG RETIN EACH 67228 $775.00 960 $542.50 $387.50 $620.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903397 PHYSICIAN FEE - OPHTHALMOLOGY PF-DRAIN EYELID ABSCESS EACH 67700 $298.00 960 $208.60 $149.00 $238.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903645 PHYSICIAN FEE - OPHTHALMOLOGY PF-ECTROPION REP EXC TARS W EACH 67916 "$1,100.00 " 960 $770.00 $550.00 $880.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903660 PHYSICIAN FEE - OPHTHALMOLOGY PF-ECTROPION REP EXTENSIVE EACH 67917 "$1,168.00 " 960 $817.60 $584.00 $934.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904387 PHYSICIAN FEE - OPHTHALMOLOGY PF-ELECTRO-OCULOMYOGR W/RPT EACH 92270 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904080 PHYSICIAN FEE - OPHTHALMOLOGY PF-EUA OPHTHALMOLOGICAL CMP EACH 92018 $350.00 960 $245.00 $175.00 $280.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904098 PHYSICIAN FEE - OPHTHALMOLOGY PF-EUA OPHTHALMOLOGICAL LTD EACH 92019 $184.00 960 $128.80 $92.00 $147.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904619 PHYSICIAN FEE - OPHTHALMOLOGY PF-EVOKED POTENTIAL VISUAL EACH 95930 $46.00 960 $32.20 $23.00 $36.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904403 PHYSICIAN FEE - OPHTHALMOLOGY PF-EXAM EYE DARK ADAPTATION EACH 92284 $95.00 960 $66.50 $47.50 $76.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904023 PHYSICIAN FEE - OPHTHALMOLOGY PF-EXPL/IRRIGATE TEAR DUCTS EACH 68840 $300.00 960 $210.00 $150.00 $240.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903330 PHYSICIAN FEE - OPHTHALMOLOGY PF-EXPLORE/TREAT EYE SOCKET EACH 67420 "$4,474.00 " 960 "$3,131.80 " "$2,237.00 " "$3,579.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904411 PHYSICIAN FEE - OPHTHALMOLOGY PF-EXTERN OCULAR PHOTOGRAPH EACH 92285 $9.00 960 $6.30 $4.50 $7.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902555 PHYSICIAN FEE - OPHTHALMOLOGY PF-EYE EXAM EST COMPREHEN EACH 92014 $189.00 960 $132.30 $94.50 $151.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902548 PHYSICIAN FEE - OPHTHALMOLOGY PF-EYE EXAM EST INTERMED EACH 92012 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902522 PHYSICIAN FEE - OPHTHALMOLOGY PF-EYE EXAM NEW COMPREHEN EACH 92004 $234.00 960 $163.80 $117.00 $187.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902514 PHYSICIAN FEE - OPHTHALMOLOGY PF-EYE EXAM NEW INTERMED EACH 92002 $113.00 960 $79.10 $56.50 $90.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904346 PHYSICIAN FEE - OPHTHALMOLOGY PF-EYE EXAM W/FUNDUS PHOTO EACH 92250 $43.00 960 $30.10 $21.50 $34.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904312 PHYSICIAN FEE - OPHTHALMOLOGY PF-EYE EXAM W/PHOTOS EACH 92230 $88.00 960 $61.60 $44.00 $70.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904593 PHYSICIAN FEE - OPHTHALMOLOGY PF-EYE PROSTHESIS SERV EACH 92358 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904452 PHYSICIAN FEE - OPHTHALMOLOGY PF-FIT LEN 1 EYE APHAKIA EACH 92311 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904478 PHYSICIAN FEE - OPHTHALMOLOGY PF-FIT LEN CORNEOSCLERAL EACH 92313 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904320 PHYSICIAN FEE - OPHTHALMOLOGY PF-FLUORESCEIN ANGIOGR S&I EACH 92235 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904106 PHYSICIAN FEE - OPHTHALMOLOGY PF-GONIOSCOPY EACH 92020 $51.00 960 $35.70 $25.50 $40.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904338 PHYSICIAN FEE - OPHTHALMOLOGY PF-ICG ANGIOGRAPHY EACH 92240 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903363 PHYSICIAN FEE - OPHTHALMOLOGY PF-INJ AGENT TH TENONS CAP EACH 67515 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903348 PHYSICIAN FEE - OPHTHALMOLOGY PF-INJ MEDS RETROBULAR EACH 67500 $167.00 960 $116.90 $83.50 $133.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904437 PHYSICIAN FEE - OPHTHALMOLOGY PF-INT EYE PHOTO EACH 92286 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904445 PHYSICIAN FEE - OPHTHALMOLOGY PF-INT EYE PHOTO ANGIOGRAPH EACH 92287 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903058 PHYSICIAN FEE - OPHTHALMOLOGY PF-IRIDOT/IREDECT LASER EACH 66761 $605.00 960 $423.50 $302.50 $484.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902852 PHYSICIAN FEE - OPHTHALMOLOGY PF-KERATPLASTY LAMELLAR EACH 65710 "$2,907.00 " 960 "$2,034.90 " "$1,453.50 " "$2,325.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902878 PHYSICIAN FEE - OPHTHALMOLOGY PF-KERATPLASTY PENETRAT APH EACH 65750 "$3,217.00 " 960 "$2,251.90 " "$1,608.50 " "$2,573.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904528 PHYSICIAN FEE - OPHTHALMOLOGY PF-MOD CONT LENS W/MD SUPER EACH 92325 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904379 PHYSICIAN FEE - OPHTHALMOLOGY PF-OCULOELECTROMYOGRAPHY EACH 92265 $108.00 960 $75.60 $54.00 $86.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904254 PHYSICIAN FEE - OPHTHALMOLOGY PF-OPHTHALMIC BIOMETRY EACH 92136 $45.00 960 $31.50 $22.50 $36.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904361 PHYSICIAN FEE - OPHTHALMOLOGY PF-OPHTHALMODYNAMOMETRY EACH 92260 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904304 PHYSICIAN FEE - OPHTHALMOLOGY PF-REM RETINAL IMAGING MGMT EACH 92228 $35.00 960 $24.50 $17.50 $28.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902944 PHYSICIAN FEE - OPHTHALMOLOGY PF-REMOVE BLOOD CLOT EYE EACH 65930 "$1,642.00 " 960 "$1,149.40 " $821.00 "$1,313.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903694 PHYSICIAN FEE - OPHTHALMOLOGY PF-REP EYELID WOUND THICK EACH 67930 $607.00 960 $424.90 $303.50 $485.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903157 PHYSICIAN FEE - OPHTHALMOLOGY PF-REP RETINAL DETACH CRYO EACH 67101 $727.00 960 $508.90 $363.50 $581.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904536 PHYSICIAN FEE - OPHTHALMOLOGY PF-REPLMNT CONTACT LENS EACH 92326 $100.00 960 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903355 PHYSICIAN FEE - OPHTHALMOLOGY PF-RETROBULBAR INJ-ALCOHOL EACH 67505 $185.00 960 $129.50 $92.50 $148.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903298 PHYSICIAN FEE - OPHTHALMOLOGY PF-REV EYE MUSCLE(S) ADD-ON EACH 67320 $447.00 960 $312.90 $223.50 $357.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903553 PHYSICIAN FEE - OPHTHALMOLOGY PF-REV EYELID W/TARS PLATE EACH 67882 "$1,204.00 " 960 $842.80 $602.00 $963.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903280 PHYSICIAN FEE - OPHTHALMOLOGY PF-REVISE TWO EYE MUSCLES EACH 67312 "$1,699.00 " 960 "$1,189.30 " $849.50 "$1,359.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902696 PHYSICIAN FEE - OPHTHALMOLOGY PF-RPR LAC CONJUNCT W/HOSP EACH 65273 $970.00 960 $679.00 $485.00 $776.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902720 PHYSICIAN FEE - OPHTHALMOLOGY PF-RPR LAC CORNEA RES TISS EACH 65285 "$2,825.00 " 960 "$1,977.50 " "$1,412.50 " "$2,260.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902704 PHYSICIAN FEE - OPHTHALMOLOGY PF-RPR LAC CORNEA W/W/O REM EACH 65275 "$1,177.00 " 960 $823.90 $588.50 $941.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903173 PHYSICIAN FEE - OPHTHALMOLOGY PF-RPR RETINA DET PHOTOCOAG EACH 67105 $701.00 960 $490.70 $350.50 $560.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97903181 PHYSICIAN FEE - OPHTHALMOLOGY PF-RPR RETINA DET W/VITRECT EACH 67108 "$3,033.00 " 960 "$2,123.10 " "$1,516.50 " "$2,426.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904601 PHYSICIAN FEE - OPHTHALMOLOGY PF-RPR/FIT SPECTACLES APHAK EACH 92371 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904247 PHYSICIAN FEE - OPHTHALMOLOGY PF-SCANNING COMP DX RETINA EACH 92134 $41.00 960 $28.70 $20.50 $32.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904239 PHYSICIAN FEE - OPHTHALMOLOGY PF-SCANNING DX OPTIC NERVE EACH 92133 $40.00 960 $28.00 $20.00 $32.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904486 PHYSICIAN FEE - OPHTHALMOLOGY PF-SCRIPT LEN 1 EYE APHAKIA EACH 92315 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904502 PHYSICIAN FEE - OPHTHALMOLOGY PF-SCRIPT LEN 2 EYE APHAKIA EACH 92316 $77.00 960 $53.90 $38.50 $61.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904510 PHYSICIAN FEE - OPHTHALMOLOGY PF-SCRIPT LEN CORNEOSCLERAL EACH 92317 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904460 PHYSICIAN FEE - OPHTHALMOLOGY PF-SCRIPT LENS 2 EYES APHAK EACH 92312 $151.00 960 $105.70 $75.50 $120.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904122 PHYSICIAN FEE - OPHTHALMOLOGY PF-SENSORIMOTOR EXAM OCULAR EACH 92060 $70.00 960 $49.00 $35.00 $56.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904205 PHYSICIAN FEE - OPHTHALMOLOGY PF-SERIAL TONOMETRY EACH 92100 $81.00 960 $56.70 $40.50 $64.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904544 PHYSICIAN FEE - OPHTHALMOLOGY PF-SPEC SPECT FT APH MON EACH 92352 $46.00 960 $32.20 $23.00 $36.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904551 PHYSICIAN FEE - OPHTHALMOLOGY PF-SPEC SPECT FT APH MUL EACH 92353 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904585 PHYSICIAN FEE - OPHTHALMOLOGY PF-SPEC SPECT FT COMP SY EACH 92355 $56.00 960 $39.20 $28.00 $44.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904577 PHYSICIAN FEE - OPHTHALMOLOGY PF-SPEC SPECT FT SNGL SY EACH 92354 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904627 PHYSICIAN FEE - OPHTHALMOLOGY PF-TENSILON TEST EACH 95857 $73.00 960 $51.10 $36.50 $58.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904130 PHYSICIAN FEE - OPHTHALMOLOGY PF-TRAIN ORTHOPTIC/PLEOPTIC EACH 92065 $83.00 960 $58.10 $41.50 $66.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904049 PHYSICIAN FEE - OPHTHALMOLOGY PF-ULTRASOUND PACHYMETRY EACH 76514 $11.00 960 $7.70 $5.50 $8.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904031 PHYSICIAN FEE - OPHTHALMOLOGY PF-US EYE B-SCAN EACH 76512 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904171 PHYSICIAN FEE - OPHTHALMOLOGY PF-VISUAL FIELD EX LIMITED EACH 92081 $40.00 960 $28.00 $20.00 $32.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904197 PHYSICIAN FEE - OPHTHALMOLOGY PF-VISUAL FIELD EXAM EXTEND EACH 92083 $67.00 960 $46.90 $33.50 $53.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97904189 PHYSICIAN FEE - OPHTHALMOLOGY PF-VISUAL FIELD EXAM INTERM EACH 92082 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96800016 PHYSICIAN FEE - PET SCANS PF-IV INJ RA DRUG DX STUDY EACH 78808 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96800008 PHYSICIAN FEE - PET SCANS PF-PET BRAIN IMAGE METABOL EVL EACH 78608 $173.00 960 $121.10 $86.50 $138.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96800024 PHYSICIAN FEE - PET SCANS PF-PET TUMOR LTD CXR/HEAD/NECK EACH 78811 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96800040 PHYSICIAN FEE - PET SCANS PF-PET TUMOR SKULL MID-THIGH EACH 78812 $226.00 960 $158.20 $113.00 $180.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96800057 PHYSICIAN FEE - PET SCANS PF-PET TUMOR WHOLE BODY EACH 78813 $231.00 960 $161.70 $115.50 $184.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96800065 PHYSICIAN FEE - PET SCANS PF-PET W/CT LIMITED AREA EACH 78814 $256.00 960 $179.20 $128.00 $204.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96800073 PHYSICIAN FEE - PET SCANS PF-PET W/CT SKULL MID-THIGH EACH 78815 $285.00 960 $199.50 $142.50 $228.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96800081 PHYSICIAN FEE - PET SCANS PF-PET W/CT TUMOR WHOLE BODY EACH 78816 $287.00 960 $200.90 $143.50 $229.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97000038 PHYSICIAN FEE - PHYSICAL THERAPY PF-PT EVAL - HIGH COMPLEXITY EACH 97163 $254.00 960 $177.80 $127.00 $203.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97000004 PHYSICIAN FEE - PHYSICAL THERAPY PF-PT EVAL - LOW COMPLEXITY EACH 97161 $254.00 960 $177.80 $127.00 $203.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97000012 PHYSICIAN FEE - PHYSICAL THERAPY PF-PT EVAL - MODERATE COMPLEX EACH 97162 $254.00 960 $177.80 $127.00 $203.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97000046 PHYSICIAN FEE - PHYSICAL THERAPY PF-PT RE-EVALUATION EACH 97164 $177.00 960 $123.90 $88.50 $141.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100241 PHYSICIAN FEE - PHYSICIAN SERVICES PF-ATTENDANCE AT DELIVERY EACH 99464 $187.00 960 $130.90 $93.50 $149.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98101041 PHYSICIAN FEE - PHYSICIAN SERVICES PF-EAR AND THROAT EXAMINATION EACH 92502 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100175 PHYSICIAN FEE - PHYSICIAN SERVICES PF-HOSP DISCH DAY - 30 MIN + EACH 99239 $295.00 960 $206.50 $147.50 $236.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100167 PHYSICIAN FEE - PHYSICIAN SERVICES PF-HOSP DISCH DAY-UP TO 30 MIN EACH 99238 $209.00 960 $146.30 $104.50 $167.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100373 PHYSICIAN FEE - PHYSICIAN SERVICES PF-ICU LBW 2501-5000 G SUBSQ EACH 99480 $300.00 960 $210.00 $150.00 $240.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100357 PHYSICIAN FEE - PHYSICIAN SERVICES PF-ICU LBW INF < 1500 GM SUBSQ EACH 99478 $343.00 960 $240.10 $171.50 $274.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100365 PHYSICIAN FEE - PHYSICIAN SERVICES PF-ICU LBW INF 1500-2500G SUBQ EACH 99479 $312.00 960 $218.40 $156.00 $249.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100340 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INIT DAY HOSP NEONATE CARE EACH 99477 $870.00 960 $609.00 $435.00 $696.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102023 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INITIAL CARE - C/C/HC EACH 99306 $469.00 960 $328.30 $234.50 $375.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102015 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INITIAL CARE - C/C/MC EACH 99305 $344.00 960 $240.80 $172.00 $275.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102007 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INITIAL CARE D-C/D-C/SF-LC EACH 99304 $208.00 960 $145.60 $104.00 $166.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100068 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INITIAL HOSP CARE-HIGH SEV EACH 99223 $448.00 960 $313.60 $224.00 $358.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100043 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INITIAL HOSP CARE-LOW SEV EACH 99221 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100050 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INITIAL HOSP CARE-MED SEV EACH 99222 $341.00 960 $238.70 $170.50 $272.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100209 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INITIAL NB CARE-SAME HOSP EACH 99460 $239.00 960 $167.30 $119.50 $191.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100217 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INITIAL NB CARE-TRANSFER EACH 99461 $158.00 960 $110.60 $79.00 $126.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100936 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INPT/ED TELECONSULT 30 EACH G0425 $243.00 960 $170.10 $121.50 $194.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100944 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INPT/ED TELECONSULT 50 EACH G0426 $342.00 960 $239.40 $171.00 $273.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100951 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INPT/ED TELECONSULT 70 EACH G0427 $477.00 960 $333.90 $238.50 $381.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100902 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INPT/TELE FOLLOW UP 15 EACH G0406 $110.00 960 $77.00 $55.00 $88.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100910 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INPT/TELE FOLLOW UP 25 EACH G0407 $188.00 960 $131.60 $94.00 $150.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100928 PHYSICIAN FEE - PHYSICIAN SERVICES PF-INPT/TELE FOLLOW UP 35 EACH G0408 $274.00 960 $191.80 $137.00 $219.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100423 PHYSICIAN FEE - PHYSICIAN SERVICES PF-IP CONSULT - COMPLEX EACH 99255 $448.00 960 $313.60 $224.00 $358.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100415 PHYSICIAN FEE - PHYSICIAN SERVICES PF-IP CONSULT - HIGH SEVERITY EACH 99254 $341.00 960 $238.70 $170.50 $272.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100399 PHYSICIAN FEE - PHYSICIAN SERVICES PF-IP CONSULT - LOW SEVERITY EACH 99252 $204.00 960 $142.80 $102.00 $163.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100407 PHYSICIAN FEE - PHYSICIAN SERVICES PF-IP CONSULT - MODERATE SEV EACH 99253 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100282 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NEONATE CRIT CARE INITIAL EACH 99468 "$2,296.00 " 960 "$1,607.20 " "$1,148.00 " "$1,836.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100290 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NEONATE CRIT CARE SUBSQ EACH 99469 $993.00 960 $695.10 $496.50 $794.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100258 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NEWBORN RESUSCITATION EACH 99465 $365.00 960 $255.50 $182.50 $292.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102072 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NH DISCHARGE < 30 MINUTES EACH 99315 $210.00 960 $147.00 $105.00 $168.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102080 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NH DISCHARGE > 30 MINUTES EACH 99316 $338.00 960 $236.60 $169.00 $270.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100506 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NTRPROF PH/NTRNET/EHR 11-20 EACH 99447 $96.00 960 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100514 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NTRPROF PH/NTRNET/EHR 21-30 EACH 99448 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100522 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NTRPROF PH/NTRNET/EHR 31/> EACH 99449 $186.00 960 $130.20 $93.00 $148.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100530 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NTRPROF PH/NTRNET/EHR 5/> EACH 99451 $91.00 960 $63.70 $45.50 $72.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100480 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NTRPROF PH/NTRNET/EHR 5-10 EACH 99446 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100548 PHYSICIAN FEE - PHYSICIAN SERVICES PF-NTRPROF PH/NTRNET/EHR RFRL EACH 99452 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100159 PHYSICIAN FEE - PHYSICIAN SERVICES PF-OBS/HOSP SAME DATE-HIGH SEV EACH 99236 $538.00 960 $376.60 $269.00 $430.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100134 PHYSICIAN FEE - PHYSICIAN SERVICES PF-OBS/HOSP SAME DATE-LOW SEV EACH 99234 $255.00 960 $178.50 $127.50 $204.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100142 PHYSICIAN FEE - PHYSICIAN SERVICES PF-OBS/HOSP SAME DATE-MOD SEV EACH 99235 $412.00 960 $288.40 $206.00 $329.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100308 PHYSICIAN FEE - PHYSICIAN SERVICES PF-PED CRIT CARE INIT 1-24 MO EACH 99471 "$1,991.00 " 960 "$1,393.70 " $995.50 "$1,592.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100324 PHYSICIAN FEE - PHYSICIAN SERVICES PF-PED CRIT CARE INIT AGE 2-5 EACH 99475 "$1,447.00 " 960 "$1,012.90 " $723.50 "$1,157.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100316 PHYSICIAN FEE - PHYSICIAN SERVICES PF-PED CRIT CARE SUBSQ 1-24 MO EACH 99472 "$1,026.00 " 960 $718.20 $513.00 $820.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100332 PHYSICIAN FEE - PHYSICIAN SERVICES PF-PED CRIT CARE SUBSQ AGE 2-5 EACH 99476 $871.00 960 $609.70 $435.50 $696.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100266 PHYSICIAN FEE - PHYSICIAN SERVICES PF-PED CRIT CARE TRANS 30-74 M EACH 99466 $596.00 960 $417.20 $298.00 $476.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100274 PHYSICIAN FEE - PHYSICIAN SERVICES PF-PED CRIT CARE TRANS ADD 30M EACH 99467 $300.00 960 $210.00 $150.00 $240.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100977 PHYSICIAN FEE - PHYSICIAN SERVICES PF-PHYSICIAN STANDBY SERVICES EACH 99360 $150.00 960 $105.00 $75.00 $120.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98101074 PHYSICIAN FEE - PHYSICIAN SERVICES "PF-PPPS, INITIAL VISIT " EACH G0438 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98101033 PHYSICIAN FEE - PHYSICIAN SERVICES "PF-PPPS, SUBSEQ VISIT " EACH G0439 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102106 PHYSICIAN FEE - PHYSICIAN SERVICES PF-PROLNG IP/OBS E/M EA 15 MIN EACH 99418 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100233 PHYSICIAN FEE - PHYSICIAN SERVICES PF-SAME DAY NEWBORN DISCHARGE EACH 99463 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102064 PHYSICIAN FEE - PHYSICIAN SERVICES PF-SUBS CARE C/C/HC EACH 99310 $397.00 960 $277.90 $198.50 $317.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102056 PHYSICIAN FEE - PHYSICIAN SERVICES PF-SUBS CARE D/D/MC EACH 99309 $277.00 960 $193.90 $138.50 $221.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102049 PHYSICIAN FEE - PHYSICIAN SERVICES PF-SUBS CARE EPF/EPF/LC EACH 99308 $192.00 960 $134.40 $96.00 $153.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98102031 PHYSICIAN FEE - PHYSICIAN SERVICES PF-SUBS CARE FF/PF/SF EACH 99307 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100100 PHYSICIAN FEE - PHYSICIAN SERVICES PF-SUBSEQ HOSP CARE-IMPROVING EACH 99231 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100118 PHYSICIAN FEE - PHYSICIAN SERVICES PF-SUBSEQ HOSP CARE-MINOR COMP EACH 99232 $204.00 960 $142.80 $102.00 $163.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100126 PHYSICIAN FEE - PHYSICIAN SERVICES PF-SUBSEQ HOSP CARE-SIGN COMPL EACH 99233 $307.00 960 $214.90 $153.50 $245.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100225 PHYSICIAN FEE - PHYSICIAN SERVICES PF-SUBSEQ NEWBORN CARE EACH 99462 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98101017 PHYSICIAN FEE - PHYSICIAN SERVICES PF-TCRAN MAGN STIM REDETEMINE EACH 90869 $799.00 960 $559.30 $399.50 $639.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98100969 PHYSICIAN FEE - PHYSICIAN SERVICES PF-TELEHEALTH INPT PHARM MGMT EACH G0459 $109.00 960 $76.30 $54.50 $87.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902851 PHYSICIAN FEE - PSYCH PF-1ST PSYC COLLAB CARE MGT EACH 99492 $241.00 960 $168.70 $120.50 $192.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902877 PHYSICIAN FEE - PSYCH PF-A-1ST/SBSQ PSYC COLLB CARE EACH 99494 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902844 PHYSICIAN FEE - PSYCH PF-ASSMT/CARE PLN PT COG IM EACH 99483 $497.00 960 $347.90 $248.50 $397.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902653 PHYSICIAN FEE - PSYCH PF-BRIEF EMOTIONAL/BH ASSMT EACH 96127 $13.00 960 $9.10 $6.50 $10.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902513 PHYSICIAN FEE - PSYCH PF-ELECTROCONVULSIVE THER EACH 90870 $267.00 960 $186.90 $133.50 $213.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902638 PHYSICIAN FEE - PSYCH PF-EXM NEUROBHV PSYCH 1ST H EACH 96116 $203.00 960 $142.10 $101.50 $162.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902646 PHYSICIAN FEE - PSYCH PF-EXM NEUROBHV PSYCH ADD H EACH 96121 $166.00 960 $116.20 $83.00 $132.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902588 PHYSICIAN FEE - PSYCH PF-FUNCTIONAL BRAIN MAPPING EACH 96020 $226.00 960 $158.20 $113.00 $180.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902737 PHYSICIAN FEE - PSYCH PF-HEALTH/BEHAV EVAL/REEVAL EACH 96156 $224.00 960 $156.80 $112.00 $179.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902828 PHYSICIAN FEE - PSYCH PF-HLTH/BEHAV FAM ONLY +15M EACH 96171 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902810 PHYSICIAN FEE - PSYCH PF-HLTH/BEHAV FAM ONLY 30 M EACH 96170 $188.00 960 $131.60 $94.00 $150.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902802 PHYSICIAN FEE - PSYCH PF-HLTH/BEHAV FAM W/PT +15M EACH 96168 $56.00 960 $39.20 $28.00 $44.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902794 PHYSICIAN FEE - PSYCH PF-HLTH/BEHAV FAM W/PT 30 M EACH 96167 $157.00 960 $109.90 $78.50 $125.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902745 PHYSICIAN FEE - PSYCH PF-HLTH/BEHAVE 30 MIN EACH 96158 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902752 PHYSICIAN FEE - PSYCH PF-HLTH/BEHAVE ADDL 15 MIN EACH 96159 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902786 PHYSICIAN FEE - PSYCH PF-HLTH/BEHAVE GROUP +15 M EACH 96165 $10.00 960 $7.00 $5.00 $8.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902778 PHYSICIAN FEE - PSYCH PF-HLTH/BEHAVE GROUP 30 MIN EACH 96164 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902307 PHYSICIAN FEE - PSYCH PF-INTERACTIVE COMPL ADDON EACH 90785 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902729 PHYSICIAN FEE - PSYCH PF-NEUROPSYCH TEST ADM +30 EACH 96137 $45.00 960 $31.50 $22.50 $36.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902711 PHYSICIAN FEE - PSYCH PF-NEUROPSYCH TEST ADM 30 M EACH 96136 $59.00 960 $41.30 $29.50 $47.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902703 PHYSICIAN FEE - PSYCH PF-NEUROPSYCH TESTING + HR EACH 96133 $191.00 960 $133.70 $95.50 $152.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902687 PHYSICIAN FEE - PSYCH PF-NEUROPSYCH TESTING 1ST H EACH 96132 $267.00 960 $186.90 $133.50 $213.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902497 PHYSICIAN FEE - PSYCH PF-PHARMACOLOG MGT W/PSYCTH EACH 90863 $61.00 960 $42.70 $30.50 $48.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902562 PHYSICIAN FEE - PSYCH PF-PSY INTERPRET FAMILY EACH 90887 $185.00 960 $129.50 $92.50 $148.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902505 PHYSICIAN FEE - PSYCH PF-PSY NARCOSYNTHESIS EACH 90865 $312.00 960 $218.40 $156.00 $249.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902430 PHYSICIAN FEE - PSYCH PF-PSY PSYCHOANLYS EACH 90845 $221.00 960 $154.70 $110.50 $176.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902315 PHYSICIAN FEE - PSYCH PF-PSYCH DX EVAL EACH 90791 $375.00 960 $262.50 $187.50 $300.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902323 PHYSICIAN FEE - PSYCH PF-PSYCH DX EVAL W/MED SRVC EACH 90792 $434.00 960 $303.80 $217.00 $347.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902471 PHYSICIAN FEE - PSYCH PF-PSYCH GROUP PSYCHOTHER EACH 90853 $62.00 960 $43.40 $31.00 $49.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902547 PHYSICIAN FEE - PSYCH PF-PSYCH HYPNOTHRPY EACH 90880 $218.00 960 $152.60 $109.00 $174.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902521 PHYSICIAN FEE - PSYCH PF-PSYCH TH BIOFEEDBK 20-30 EACH 90875 $150.00 960 $105.00 $75.00 $120.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902539 PHYSICIAN FEE - PSYCH PF-PSYCH TH BIOFEEDBK 45-50 EACH 90876 $239.00 960 $167.30 $119.50 $191.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902463 PHYSICIAN FEE - PSYCH PF-PSYCH TH GRP FAM MULTI EACH 90849 $75.00 960 $52.50 $37.50 $60.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902455 PHYSICIAN FEE - PSYCH PF-PSYCH THRPY FAMILY W/PT EACH 90847 $258.00 960 $180.60 $129.00 $206.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902448 PHYSICIAN FEE - PSYCH PF-PSYCH THRPY FAMILY WO PT EACH 90846 $247.00 960 $172.90 $123.50 $197.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902604 PHYSICIAN FEE - PSYCH PF-PSYCH-DEV TEST FIRST HR EACH 96112 $318.00 960 $222.60 $159.00 $254.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902612 PHYSICIAN FEE - PSYCH PF-PSYCH-DEV TESTING EA +HR EACH 96113 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902661 PHYSICIAN FEE - PSYCH PF-PSYCHOLOGC TESTING 1ST H EACH 96130 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902679 PHYSICIAN FEE - PSYCH PF-PSYCHOLOGIC TESTING +HR EACH 96131 $190.00 960 $133.00 $95.00 $152.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902422 PHYSICIAN FEE - PSYCH PF-PSYCHOTH CRISIS +30 MIN EACH 90840 $167.00 960 $116.90 $83.50 $133.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902406 PHYSICIAN FEE - PSYCH PF-PSYCHOTH CRISIS; 1ST 60 EACH 90839 $328.00 960 $229.60 $164.00 $262.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902356 PHYSICIAN FEE - PSYCH "PF-PSYCHOTH, 30 MIN W/E&M " EACH 90833 $165.00 960 $115.50 $82.50 $132.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902331 PHYSICIAN FEE - PSYCH "PF-PSYCHOTH, 30 MINUTES " EACH 90832 $174.00 960 $121.80 $87.00 $139.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902372 PHYSICIAN FEE - PSYCH "PF-PSYCHOTH, 45 MIN W/E&M " EACH 90836 $208.00 960 $145.60 $104.00 $166.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902364 PHYSICIAN FEE - PSYCH "PF-PSYCHOTH, 45 MINUTES " EACH 90834 $229.00 960 $160.30 $114.50 $183.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902380 PHYSICIAN FEE - PSYCH "PF-PSYCHOTH, 60 MINUTES " EACH 90837 $338.00 960 $236.60 $169.00 $270.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902570 PHYSICIAN FEE - PSYCH PF-REPORT PREP - PSYCH EACH 90889 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902869 PHYSICIAN FEE - PSYCH PF-SBSQ PSYC COLLB CARE MGT EACH 99493 $265.00 960 $185.50 $132.50 $212.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902885 PHYSICIAN FEE - PSYCH PF-STD COG TEST HC PRO HR EACH 96125 $260.00 960 $182.00 $130.00 $208.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600126 PHYSICIAN FEE - PULMONARY PF-AEROSOL INHALAT PENTAMIDINE EACH 94642 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600183 PHYSICIAN FEE - PULMONARY PF-AEROSOL NEB/MDI/IPPB EVAL EACH 94664 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600605 PHYSICIAN FEE - PULMONARY PF-AIRWAY INHALATION TREATMENT EACH 94640 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600399 PHYSICIAN FEE - PULMONARY PF-BREATHING RESPONSE HYPOXIA EACH 94450 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600290 PHYSICIAN FEE - PULMONARY PF-BRONCHIAL ALLERGY TESTS EACH 95070 $90.00 960 $63.00 $45.00 $72.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600522 PHYSICIAN FEE - PULMONARY PF-C02/MEMBANE DIFFUSE CAPACTY EACH 94729 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600282 PHYSICIAN FEE - PULMONARY PF-CAR SEAT/BED TEST + 30 MIN EACH 94781 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600266 PHYSICIAN FEE - PULMONARY PF-CAR SEAT/BED TEST 60 MIN EACH 94780 $60.00 960 $42.00 $30.00 $48.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600191 PHYSICIAN FEE - PULMONARY PF-CHEST PHYSIOTHRPY INITIAL EACH 94667 $65.00 960 $45.50 $32.50 $52.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600217 PHYSICIAN FEE - PULMONARY PF-CHEST PHYSIOTHRPY SUBSEQ EACH 94668 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600175 PHYSICIAN FEE - PULMONARY PF-CNP INITIATION/MANAGEMENT EACH 94662 $91.00 960 $63.70 $45.50 $72.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600159 PHYSICIAN FEE - PULMONARY PF-CONT INHAL TX EA ADDL HR EACH 94645 $42.00 960 $29.40 $21.00 $33.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600142 PHYSICIAN FEE - PULMONARY PF-CONTINUOUS INHAL TX 1ST HR EACH 94644 $152.00 960 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600167 PHYSICIAN FEE - PULMONARY PF-CPAP/BIPAP INITIAT/MANAGE EACH 94660 $96.00 960 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600001 PHYSICIAN FEE - PULMONARY PF-CPR EACH 92950 $481.00 960 $336.70 $240.50 $384.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600704 PHYSICIAN FEE - PULMONARY PF-EXERCISE TST BRNCSPSM EACH 94617 $78.00 960 $54.60 $39.00 $62.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600373 PHYSICIAN FEE - PULMONARY PF-FLOW VOLUME LOOP EACH 94375 $36.00 960 $25.20 $18.00 $28.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600050 PHYSICIAN FEE - PULMONARY PF-FOR EXP FLOW W/DIL TO 2 YRS EACH 94012 $356.00 960 $249.20 $178.00 $284.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600423 PHYSICIAN FEE - PULMONARY PF-HAST W/OXYGEN TITRATE EACH 94453 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600407 PHYSICIAN FEE - PULMONARY PF-HAST W/REPORT EACH 94452 $35.00 960 $24.50 $17.50 $28.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600589 PHYSICIAN FEE - PULMONARY "PF-HBOT, FULL BODY CHAMBER 30M" EACH G0277 $462.00 960 $323.40 $231.00 $369.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600357 PHYSICIAN FEE - PULMONARY PF-MAXIMUM VOLUNTARY VENT EACH 94200 $8.00 960 $5.60 $4.00 $6.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600076 PHYSICIAN FEE - PULMONARY PF-MEAS LUNG VOL THRU 2 YRS EACH 94013 $48.00 960 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600225 PHYSICIAN FEE - PULMONARY PF-MECHANICAL CHEST WALL OSCIL EACH 94669 $54.00 960 $37.80 $27.00 $43.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600456 PHYSICIAN FEE - PULMONARY PF-O2 UPTAKE EXP GAS REST/EXR EACH 94680 $33.00 960 $23.10 $16.50 $26.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600472 PHYSICIAN FEE - PULMONARY PF-O2 UPTAKE EXPIRED GAS REST EACH 94690 $10.00 960 $7.00 $5.00 $8.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600464 PHYSICIAN FEE - PULMONARY PF-O2 UPTAKE EXPIRED GAS W/CO2 EACH 94681 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600571 PHYSICIAN FEE - PULMONARY "PF-OT/PTH RESP PROC, GROUP " EACH G0239 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600563 PHYSICIAN FEE - PULMONARY "PF-OT/PTH RESP PROC, INDIV " EACH G0238 $27.00 960 $18.90 $13.50 $21.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600092 PHYSICIAN FEE - PULMONARY PF-PATIENT RECORDED SPIROMETRY EACH 94015 $82.00 960 $57.40 $41.00 $65.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600647 PHYSICIAN FEE - PULMONARY PF-PHY/QHP OP PULM RHB W/MNTR EACH 94626 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600639 PHYSICIAN FEE - PULMONARY PF-PHY/QHP OP PULM RHB WO MNTR EACH 94625 $49.00 960 $34.30 $24.50 $39.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600084 PHYSICIAN FEE - PULMONARY PF-PT RECORDED SPIROMETRY R&I EACH 94014 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600514 PHYSICIAN FEE - PULMONARY PF-PULM FUNC TEST OSCILLOMETRY EACH 94728 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600498 PHYSICIAN FEE - PULMONARY PF-PULM FUNC TST PLETHYSMOGRAP EACH 94726 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600506 PHYSICIAN FEE - PULMONARY PF-PULM FUNCTION TEST BY GAS EACH 94727 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600597 PHYSICIAN FEE - PULMONARY PF-PULMONARY REHAB W EXER EACH 94626 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600597 PHYSICIAN FEE - PULMONARY PF-PULMONARY REHAB W EXER EACH G0424 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600449 PHYSICIAN FEE - PULMONARY PF-PULMONARY STRESS TEST CPLX EACH 94621 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600431 PHYSICIAN FEE - PULMONARY PF-PULMONARY STRESS TEST SMP EACH 94618 $32.00 960 $22.40 $16.00 $25.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600241 PHYSICIAN FEE - PULMONARY PF-PULSE OX OVERNIGHT EACH 94762 $65.00 960 $45.50 $32.50 $52.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600233 PHYSICIAN FEE - PULMONARY PF-PULSE OX SINGLE EACH 94760 $8.00 960 $5.60 $4.00 $6.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600100 PHYSICIAN FEE - PULMONARY PF-REVIEW PATIENT SPIROMETRY EACH 94016 $62.00 960 $43.40 $31.00 $49.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600043 PHYSICIAN FEE - PULMONARY PF-SPIROMETRY UP TO 2 YRS OLD EACH 94011 $218.00 960 $152.60 $109.00 $174.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600316 PHYSICIAN FEE - PULMONARY PF-SPIROMETRY/PFT EACH 94010 $21.00 960 $14.70 $10.50 $16.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600332 PHYSICIAN FEE - PULMONARY PF-SPIROMETRY/PFT CPLX EACH 94070 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600324 PHYSICIAN FEE - PULMONARY PF-SPIROMETRY/PFT PRE & POST EACH 94060 $26.00 960 $18.20 $13.00 $20.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600118 PHYSICIAN FEE - PULMONARY PF-SURFACT ADMIN BY DR THRU TB EACH 94610 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600613 PHYSICIAN FEE - PULMONARY PF-TELE-PULMONARY REHAB W EXER EACH 94626 $72.00 960 $50.40 $36.00 $57.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600548 PHYSICIAN FEE - PULMONARY PF-THERAPEUT PROCD STRG ENDUR EACH G0237 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600035 PHYSICIAN FEE - PULMONARY PF-VENT MGMT NF PER DAY EACH 94004 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600019 PHYSICIAN FEE - PULMONARY PF-VENT MGT INPT/OBS INIT DAY EACH 94002 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97600027 PHYSICIAN FEE - PULMONARY PF-VENT MGT INPT/OBS SUBS DAY EACH 94003 $167.00 960 $116.90 $83.50 $133.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300678 PHYSICIAN FEE - RADIATION THERAPY PF-APPLY SURFACE RADIATION EACH 77789 $153.00 960 $107.10 $76.50 $122.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300181 PHYSICIAN FEE - RADIATION THERAPY PF-BRACHYTX ISODOSE COMPLEX EACH 77318 $385.00 960 $269.50 $192.50 $308.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300173 PHYSICIAN FEE - RADIATION THERAPY PF-BRACHYTX ISODOSE INTERM EACH 77317 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300157 PHYSICIAN FEE - RADIATION THERAPY PF-BRACHYTX ISODOSE PLAN SMP EACH 77316 $187.00 960 $130.90 $93.50 $149.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300017 PHYSICIAN FEE - RADIATION THERAPY PF-CT PLACE RAD THER FIELDS EACH 77014 $114.00 960 $79.80 $57.00 $91.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300876 PHYSICIAN FEE - RADIATION THERAPY PF-DELIVERY COMP IMRT EACH G6016 $891.00 960 $623.70 $445.50 $712.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300207 PHYSICIAN FEE - RADIATION THERAPY PF-DOSIMETRY CALC SPECIAL EACH 77331 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300116 PHYSICIAN FEE - RADIATION THERAPY PF-DOSIMETRY CALCULATION BASIC EACH 77300 $83.00 960 $58.10 $41.50 $66.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300314 PHYSICIAN FEE - RADIATION THERAPY PF-EXTERN RADIATION DOSIMETRY EACH 77399 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300520 PHYSICIAN FEE - RADIATION THERAPY PF-HYPERTHER INTERSTITIAL TO 5 EACH 77610 $176.00 960 $123.20 $88.00 $140.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300496 PHYSICIAN FEE - RADIATION THERAPY PF-HYPERTHERM HEATING TO 4 CM EACH 77600 $181.00 960 $126.70 $90.50 $144.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300538 PHYSICIAN FEE - RADIATION THERAPY PF-HYPERTHERM INTERSTITIAL >5 EACH 77615 $247.00 960 $172.90 $123.50 $197.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300504 PHYSICIAN FEE - RADIATION THERAPY PF-HYPERTHERMIA HEATING > 4 CM EACH 77605 $276.00 960 $193.20 $138.00 $220.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300546 PHYSICIAN FEE - RADIATION THERAPY PF-HYPERTHERMIA INTRACATARY EACH 77620 $233.00 960 $163.10 $116.50 $186.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300553 PHYSICIAN FEE - RADIATION THERAPY PF-INFUSE RADIOACTIVE MATERIAL EACH 77750 $338.00 960 $236.60 $169.00 $270.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300124 PHYSICIAN FEE - RADIATION THERAPY PF-INTENSITY MOD TX PLAN EACH 77301 "$1,064.00 " 960 $744.80 $532.00 $851.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300629 PHYSICIAN FEE - RADIATION THERAPY PF-INTERSTITIAL BRACHY CPLX EACH 77778 "$1,166.00 " 960 $816.20 $583.00 $932.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300595 PHYSICIAN FEE - RADIATION THERAPY PF-INTRACAVITARY BRACHY CPLX EACH 77763 $843.00 960 $590.10 $421.50 $674.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300561 PHYSICIAN FEE - RADIATION THERAPY PF-INTRACAVITARY BRACHY SMP EACH 77761 $513.00 960 $359.10 $256.50 $410.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300579 PHYSICIAN FEE - RADIATION THERAPY PF-INTRACAVITRY BRACH INTERMED EACH 77762 $645.00 960 $451.50 $322.50 $516.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300884 PHYSICIAN FEE - RADIATION THERAPY PF-INTRA-FRACTION LOCALIZATION EACH G6017 $56.00 960 $39.20 $28.00 $44.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300413 PHYSICIAN FEE - RADIATION THERAPY PF-IO RADIATION TX MANAGEMENT EACH 77469 $828.00 960 $579.60 $414.00 $662.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300256 PHYSICIAN FEE - RADIATION THERAPY PF-MED PHYSICS CONSULT-WEEKLY EACH 77336 $231.00 960 $161.70 $115.50 $184.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300264 PHYSICIAN FEE - RADIATION THERAPY PF-MLC DEVICE CONST/IMRT PLAN EACH 77338 $571.00 960 $399.70 $285.50 $456.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300355 PHYSICIAN FEE - RADIATION THERAPY PF-NEUTRON BEAM TX COMPLEX EACH 77423 $172.00 960 $120.40 $86.00 $137.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300199 PHYSICIAN FEE - RADIATION THERAPY PF-PORT PLAN SPECIAL EACH 77321 $114.00 960 $79.80 $57.00 $91.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300488 PHYSICIAN FEE - RADIATION THERAPY PF-PROTON TREATMENT COMPLEX EACH 77525 "$2,527.00 " 960 "$1,768.90 " "$1,263.50 " "$2,021.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300470 PHYSICIAN FEE - RADIATION THERAPY PF-PROTON TRMT INTERMEDIATE EACH 77523 "$2,374.00 " 960 "$1,661.80 " "$1,187.00 " "$1,899.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300462 PHYSICIAN FEE - RADIATION THERAPY PF-PROTON TRMT SIMPLE W/COMP EACH 77522 "$2,001.00 " 960 "$1,400.70 " "$1,000.50 " "$1,600.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300454 PHYSICIAN FEE - RADIATION THERAPY PF-PROTON TRMT SIMPLE W/O COMP EACH 77520 "$1,949.00 " 960 "$1,364.30 " $974.50 "$1,559.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300389 PHYSICIAN FEE - RADIATION THERAPY PF-RAD THER MGT 1-2 FRACTIONS EACH 77431 $280.00 960 $196.00 $140.00 $224.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300058 PHYSICIAN FEE - RADIATION THERAPY PF-RAD THER PLANNING COMPLEX EACH 77263 $435.00 960 $304.50 $217.50 $348.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300041 PHYSICIAN FEE - RADIATION THERAPY PF-RAD THER PLANNING INTERMED EACH 77262 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300033 PHYSICIAN FEE - RADIATION THERAPY PF-RAD THER PLANNING SIMPLE EACH 77261 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300835 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX COMPLEX 11-19 MEV EACH G6013 $582.00 960 $407.40 $291.00 $465.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300843 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX COMPLEX 20+ MEV EACH G6014 $577.00 960 $403.90 $288.50 $461.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300827 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX COMPLEX 6-10 MEV EACH G6012 $579.00 960 $405.30 $289.50 $463.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300819 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX COMPLEX TO 5 MEV EACH G6011 $578.00 960 $404.60 $289.00 $462.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300785 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX INTERMED 11-19 MEV EACH G6009 $439.00 960 $307.30 $219.50 $351.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300801 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX INTERMED 20+ MEV EACH G6010 $436.00 960 $305.20 $218.00 $348.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300777 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX INTERMED 6-10 MEV EACH G6008 $440.00 960 $308.00 $220.00 $352.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300769 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX INTERMED TO 5 MEV EACH G6007 $579.00 960 $405.30 $289.50 $463.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300744 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX SIMPLE 11-19 MEV EACH G6005 $320.00 960 $224.00 $160.00 $256.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300751 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX SIMPLE 20+ MEV EACH G6006 $317.00 960 $221.90 $158.50 $253.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300736 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX SIMPLE 6-10 MEV EACH G6004 $319.00 960 $223.30 $159.50 $255.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300710 PHYSICIAN FEE - RADIATION THERAPY PF-RAD TX SIMPLE TO 5 MEV EACH G6003 $388.00 960 $271.60 $194.00 $310.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300272 PHYSICIAN FEE - RADIATION THERAPY PF-RADIATION PHYSICS CONSULT EACH 77370 $376.00 960 $263.20 $188.00 $300.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300322 PHYSICIAN FEE - RADIATION THERAPY PF-RADIATION TX DELIVERY EACH 77401 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300850 PHYSICIAN FEE - RADIATION THERAPY PF-RADIATION TX DELIVERY IMRT EACH G6015 $900.00 960 $630.00 $450.00 $720.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300363 PHYSICIAN FEE - RADIATION THERAPY PF-RADIATION TX MANAGEMENT X5 EACH 77427 $495.00 960 $346.50 $247.50 $396.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300686 PHYSICIAN FEE - RADIATION THERAPY PF-RADIOELEM HANDLING/LOADING EACH 77790 $47.00 960 $32.90 $23.50 $37.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300330 PHYSICIAN FEE - RADIATION THERAPY PF-RADIOLOGY PORT FILM(S) EACH 77417 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300694 PHYSICIAN FEE - RADIATION THERAPY PF-ROBOT LIN-RADSURG COM FIRST EACH G0339 "$1,181.00 " 960 $826.70 $590.50 $944.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300702 PHYSICIAN FEE - RADIATION THERAPY PF-ROBT LIN-RADSURG FRACTX 2-5 EACH G0340 "$1,933.00 " 960 "$1,353.10 " $966.50 "$1,546.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300298 PHYSICIAN FEE - RADIATION THERAPY PF-SBRT DELIVERY EACH 77373 "$2,521.00 " 960 "$1,764.70 " "$1,260.50 " "$2,016.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300405 PHYSICIAN FEE - RADIATION THERAPY PF-SBRT MANAGEMENT EACH 77435 "$1,667.00 " 960 "$1,166.90 " $833.50 "$1,333.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300108 PHYSICIAN FEE - RADIATION THERAPY PF-SIMULATION 3-D/CT GUIDED EACH 77295 $571.00 960 $399.70 $285.50 $456.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300082 PHYSICIAN FEE - RADIATION THERAPY PF-SIMULATION CPLX EACH 77290 $209.00 960 $146.30 $104.50 $167.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300074 PHYSICIAN FEE - RADIATION THERAPY PF-SIMULATION INTERMED EACH 77285 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300066 PHYSICIAN FEE - RADIATION THERAPY PF-SIMULATION SMP EACH 77280 $96.00 960 $67.20 $48.00 $76.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300421 PHYSICIAN FEE - RADIATION THERAPY PF-SPECIAL RADIATION TREATMENT EACH 77470 $93.00 960 $65.10 $46.50 $74.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300280 PHYSICIAN FEE - RADIATION THERAPY PF-SRS LINEAR BASED EACH 77372 "$2,411.00 " 960 "$1,687.70 " "$1,205.50 " "$1,928.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300397 PHYSICIAN FEE - RADIATION THERAPY PF-STEREOTACTIC RADIATION TRMT EACH 77432 "$1,102.00 " 960 $771.40 $551.00 $881.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300140 PHYSICIAN FEE - RADIATION THERAPY PF-TELETHX ISODOSE PLAN COMPLX EACH 77307 $346.00 960 $242.20 $173.00 $276.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300132 PHYSICIAN FEE - RADIATION THERAPY PF-TELETHX ISODOSE PLAN SIMPLE EACH 77306 $187.00 960 $130.90 $93.50 $149.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300249 PHYSICIAN FEE - RADIATION THERAPY PF-TREATMENT DEVICE CPLX EACH 77334 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300223 PHYSICIAN FEE - RADIATION THERAPY PF-TREATMENT DEVICE INTERMED EACH 77333 $100.00 960 $70.00 $50.00 $80.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96300215 PHYSICIAN FEE - RADIATION THERAPY PF-TREATMENT DEVICE SMP EACH 77332 $41.00 960 $28.70 $20.50 $32.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600041 PHYSICIAN FEE - SLEEP PF-ACTIGRAPHY TESTING EACH 95803 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600009 PHYSICIAN FEE - SLEEP PF-HOME SLEEP TEST/TYPE 2 PORT EACH G0398 $232.00 960 $162.40 $116.00 $185.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600017 PHYSICIAN FEE - SLEEP PF-HOME SLEEP TEST/TYPE 3 PORT EACH G0399 $118.00 960 $82.60 $59.00 $94.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600025 PHYSICIAN FEE - SLEEP PF-HOME SLEEP TEST/TYPE 4 PORT EACH G0400 $232.00 960 $162.40 $116.00 $185.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600074 PHYSICIAN FEE - SLEEP PF-MULT SLEEP/WAKE LAT (MSLT) EACH 95805 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600132 PHYSICIAN FEE - SLEEP PF-POLYSOM <6 YRS 4/> PARAMTRS EACH 95782 $308.00 960 $215.60 $154.00 $246.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600157 PHYSICIAN FEE - SLEEP PF-POLYSOM <6 YRS CPAP/BILVL EACH 95783 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600116 PHYSICIAN FEE - SLEEP PF-PSG 1-3 PARAMETERS EACH 95808 $207.00 960 $144.90 $103.50 $165.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600140 PHYSICIAN FEE - SLEEP PF-PSG 4 OR > PARAMETERS EACH 95811 $308.00 960 $215.60 $154.00 $246.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600124 PHYSICIAN FEE - SLEEP PF-PSG 4+ PARAMETERS (PSG) EACH 95810 $295.00 960 $206.50 $147.50 $236.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600058 PHYSICIAN FEE - SLEEP PF-SLEEP ST UNATND W/RESP ANAL EACH 95801 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600090 PHYSICIAN FEE - SLEEP PF-SLEEP STUDY ATTENDED EACH 95807 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600066 PHYSICIAN FEE - SLEEP PF-SLEEP STUDY UNATTENDED EACH 95800 $99.00 960 $69.30 $49.50 $79.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99600082 PHYSICIAN FEE - SLEEP PF-SLEEP STUDY UNATTENDED EACH 95806 $110.00 960 $77.00 $55.00 $88.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200257 PHYSICIAN FEE - SPEECH THERAPY PF-ASSESSMENT OF APHASIA EACH 96105 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200117 PHYSICIAN FEE - SPEECH THERAPY PF-AUD EVAL VOICE PROSTHETIC EACH 92597 $184.00 960 $128.80 $92.00 $147.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200000 PHYSICIAN FEE - SPEECH THERAPY PF-AUD TREAT SPEECH EACH 92507 $193.00 960 $135.10 $96.50 $154.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200091 PHYSICIAN FEE - SPEECH THERAPY PF-BEHAVRAL QUALIT ANLYS VOICE EACH 92524 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200190 PHYSICIAN FEE - SPEECH THERAPY PF-ENDOSCOPY SWALLOW S&I ONLY EACH 92613 $93.00 960 $65.10 $46.50 $74.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200182 PHYSICIAN FEE - SPEECH THERAPY PF-ENDOSCOPY SWALLOW TEST EACH 92612 $169.00 960 $118.30 $84.50 $135.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200216 PHYSICIAN FEE - SPEECH THERAPY PF-EVAL LARYNGOSCOPY SENSE TST EACH 92615 $84.00 960 $58.80 $42.00 $67.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200059 PHYSICIAN FEE - SPEECH THERAPY PF-EVAL OF SPEECH FLUENCY EACH 92521 $337.00 960 $235.90 $168.50 $269.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200166 PHYSICIAN FEE - SPEECH THERAPY PF-EVAL SWALLOWING FUNCTION EACH 92610 $178.00 960 $124.60 $89.00 $142.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200067 PHYSICIAN FEE - SPEECH THERAPY PF-EVALUATE SPEECH PRODUCTION EACH 92522 $283.00 960 $198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200125 PHYSICIAN FEE - SPEECH THERAPY PF-EX FOR SPEECH DEVICE RX 1HR EACH 92607 $314.00 960 $219.80 $157.00 $251.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200133 PHYSICIAN FEE - SPEECH THERAPY PF-EXAM SPEECH DEVICE RX ADDL EACH 92608 $123.00 960 $86.10 $61.50 $98.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200034 PHYSICIAN FEE - SPEECH THERAPY PF-FACIAL NERVE FUNC STUDY EACH 92516 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200232 PHYSICIAN FEE - SPEECH THERAPY PF-FEES W/LARYNGEAL SENSE TEST EACH 92616 $253.00 960 $177.10 $126.50 $202.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200240 PHYSICIAN FEE - SPEECH THERAPY PF-INTERPRT FEES/LARYNGEAL TST EACH 92617 $105.00 960 $73.50 $52.50 $84.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200042 PHYSICIAN FEE - SPEECH THERAPY PF-LARYNGEAL FUNCTION STUDIES EACH 92520 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200208 PHYSICIAN FEE - SPEECH THERAPY PF-LARYNGOSCOPIC SENSORY TEST EACH 92614 $167.00 960 $116.90 $83.50 $133.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200174 PHYSICIAN FEE - SPEECH THERAPY PF-MOTION FLUOROSCOPY/SWALLOW EACH 92611 $236.00 960 $165.20 $118.00 $188.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200109 PHYSICIAN FEE - SPEECH THERAPY PF-ORAL FUNCTION THERAPY EACH 92526 $214.00 960 $149.80 $107.00 $171.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200075 PHYSICIAN FEE - SPEECH THERAPY PF-SPEECH SOUND LANG COMPREHEN EACH 92523 $576.00 960 $403.20 $288.00 $460.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200026 PHYSICIAN FEE - SPEECH THERAPY PF-SPEECH/HEARING THERAPY EACH 92508 $62.00 960 $43.40 $31.00 $49.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97200141 PHYSICIAN FEE - SPEECH THERAPY PF-USE OF SPEECH DEVICE SERV EACH 92609 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353477 PHYSICIAN FEE - SURGERY PF- PROBE NASOLACRIMAL DUCT EACH 68811 $347.00 960 $242.90 $173.50 $277.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337207 PHYSICIAN FEE - SURGERY PF-ABD PARACENTESIS EACH 49082 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357635 PHYSICIAN FEE - SURGERY PF-ABDOMEN SURGERY PROC NOS EACH 49999 "$1,747.00 " 960 "$1,222.90 " $873.50 "$1,397.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358682 PHYSICIAN FEE - SURGERY PF-ABDOMEN SURGERY PROC NOS EACH 36466 $417.00 960 $291.90 $208.50 $333.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323306 PHYSICIAN FEE - SURGERY PF-ABLATE ATRIA LMTD EACH 33254 "$3,803.00 " 960 "$2,662.10 " "$1,901.50 " "$3,042.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323330 PHYSICIAN FEE - SURGERY PF-ABLATE ATRIA LMTD ADD-ON EACH 33257 "$1,620.00 " 960 "$1,134.00 " $810.00 "$1,296.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323405 PHYSICIAN FEE - SURGERY PF-ABLATE ATRIA LMTD ENDO EACH 33265 "$3,799.00 " 960 "$2,659.30 " "$1,899.50 " "$3,039.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323355 PHYSICIAN FEE - SURGERY PF-ABLATE ATRIA W/BYPASS ADDON EACH 33259 "$2,354.00 " 960 "$1,647.80 " "$1,177.00 " "$1,883.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323322 PHYSICIAN FEE - SURGERY PF-ABLATE ATRIA W/BYPASS EXTEN EACH 33256 "$5,344.00 " 960 "$3,740.80 " "$2,672.00 " "$4,275.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323314 PHYSICIAN FEE - SURGERY PF-ABLATE ATRIA W/O BYPASS EXT EACH 33255 "$4,506.00 " 960 "$3,154.20 " "$2,253.00 " "$3,604.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323348 PHYSICIAN FEE - SURGERY PF-ABLATE ATRIA X10SV ADD-ON EACH 33258 "$1,797.00 " 960 "$1,257.90 " $898.50 "$1,437.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323413 PHYSICIAN FEE - SURGERY PF-ABLATE ATRIA X10SV ENDO EACH 33266 "$5,144.00 " 960 "$3,600.80 " "$2,572.00 " "$4,115.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304686 PHYSICIAN FEE - SURGERY PF-ABLATE BONE TUMOR(S) PERQ EACH 20982 $985.00 960 $689.50 $492.50 $788.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354475 PHYSICIAN FEE - SURGERY PF-ABLATE BONE TUMOR(S) PERQ EACH 20983 $897.00 960 $627.90 $448.50 $717.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323280 PHYSICIAN FEE - SURGERY PF-ABLATE HEART DYSRHYTHM FOC EACH 33250 "$3,057.00 " 960 "$2,139.90 " "$1,528.50 " "$2,445.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323298 PHYSICIAN FEE - SURGERY PF-ABLATE HEART DYSRHYTHM FOC EACH 33251 "$4,571.00 " 960 "$3,199.70 " "$2,285.50 " "$3,656.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323363 PHYSICIAN FEE - SURGERY PF-ABLATE HEART DYSRHYTHM FOC EACH 33261 "$4,467.00 " 960 "$3,126.90 " "$2,233.50 " "$3,573.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320211 PHYSICIAN FEE - SURGERY PF-ABLATE INF TURBINATE SUBMUC EACH 30802 $535.00 960 $374.50 $267.50 $428.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320203 PHYSICIAN FEE - SURGERY PF-ABLATE INF TURBINATE SUPERF EACH 30801 $398.00 960 $278.60 $199.00 $318.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358492 PHYSICIAN FEE - SURGERY PF-ABLATE PULM TUMOR PERQ CRYB EACH 32994 "$1,137.00 " 960 $795.90 $568.50 $909.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360928 PHYSICIAN FEE - SURGERY PF-ABLTJ THYR NDUL PERQ LASR EACH 0673T "$1,550.00 " 960 "$1,085.00 " $775.00 "$1,240.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345432 PHYSICIAN FEE - SURGERY PF-ABORTION EACH 59866 $695.00 960 $486.50 $347.50 $556.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345358 PHYSICIAN FEE - SURGERY PF-ABORTION EACH 59840 $638.00 960 $446.60 $319.00 $510.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345374 PHYSICIAN FEE - SURGERY PF-ABORTION EACH 59850 "$1,136.00 " 960 $795.20 $568.00 $908.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345390 PHYSICIAN FEE - SURGERY PF-ABORTION EACH 59852 "$1,693.00 " 960 "$1,185.10 " $846.50 "$1,354.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345408 PHYSICIAN FEE - SURGERY PF-ABORTION EACH 59855 "$1,235.00 " 960 $864.50 $617.50 $988.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345416 PHYSICIAN FEE - SURGERY PF-ABORTION EACH 59856 "$1,449.00 " 960 "$1,014.30 " $724.50 "$1,159.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345424 PHYSICIAN FEE - SURGERY PF-ABORTION EACH 59857 "$1,691.00 " 960 "$1,183.70 " $845.50 "$1,352.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302474 PHYSICIAN FEE - SURGERY PF-ABRASION LESION SINGLE EACH 15786 $355.00 960 $248.50 $177.50 $284.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302482 PHYSICIAN FEE - SURGERY PF-ABRASION LESIONS ADD-ON EACH 15787 $43.00 960 $30.10 $21.50 $34.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302433 PHYSICIAN FEE - SURGERY PF-ABRASION TREATMENT OF SKIN EACH 15780 "$1,733.00 " 960 "$1,213.10 " $866.50 "$1,386.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329907 PHYSICIAN FEE - SURGERY PF-ACCESS THORACIC LYMPH DUCT EACH 38794 $735.00 960 $514.50 $367.50 $588.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302425 PHYSICIAN FEE - SURGERY PF-ACELLULAR DERM MATRIX IMPLT EACH 15777 $587.00 960 $410.90 $293.50 $469.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300031 PHYSICIAN FEE - SURGERY PF-ACNE SURGERY EACH 10040 $137.00 960 $95.90 $68.50 $109.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318876 PHYSICIAN FEE - SURGERY PF-ADDITION OF WALKER TO CAST EACH 29440 $74.00 960 $51.80 $37.00 $59.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307085 PHYSICIAN FEE - SURGERY PF-ADDITIONAL SPINAL FUSION EACH 22585 $937.00 960 $655.90 $468.50 $749.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307044 PHYSICIAN FEE - SURGERY PF-ADDL NECK SPINE FUSION EACH 22552 "$1,158.00 " 960 $810.60 $579.00 $926.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344583 PHYSICIAN FEE - SURGERY PF-ADHESIOLYSIS TUBE OVARY EACH 58740 "$2,483.00 " 960 "$1,738.10 " "$1,241.50 " "$1,986.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304330 PHYSICIAN FEE - SURGERY PF-ADJUST BONE FIXATION DEVICE EACH 20693 "$1,213.00 " 960 $849.10 $606.50 $970.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337397 PHYSICIAN FEE - SURGERY PF-AIR INJECTION INTO ABDOMEN EACH 49400 $236.00 960 $165.20 $118.00 $188.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357502 PHYSICIAN FEE - SURGERY PF-AIRWAYS SURGICAL PROC NOS EACH 31899 $924.00 960 $646.80 $462.00 $739.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319452 PHYSICIAN FEE - SURGERY PF-ALLGRFT IMPLNT KNEE W/SCOPE EACH 29867 "$3,519.00 " 960 "$2,463.30 " "$1,759.50 " "$2,815.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344856 PHYSICIAN FEE - SURGERY PF-AMNIOCENTESIS DIAGNOSTIC EACH 59000 $235.00 960 $164.50 $117.50 $188.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344864 PHYSICIAN FEE - SURGERY PF-AMNIOCENTESIS THERAPEUTIC EACH 59001 $520.00 960 $364.00 $260.00 $416.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311202 PHYSICIAN FEE - SURGERY PF-AMPUTATE HAND AT WRIST EACH 25920 "$1,999.00 " 960 "$1,399.30 " $999.50 "$1,599.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311210 PHYSICIAN FEE - SURGERY PF-AMPUTATE HAND AT WRIST EACH 25922 "$1,770.00 " 960 "$1,239.00 " $885.00 "$1,416.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315518 PHYSICIAN FEE - SURGERY PF-AMPUTATE LEG AT THIGH EACH 27590 "$2,212.00 " 960 "$1,548.40 " "$1,106.00 " "$1,769.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315526 PHYSICIAN FEE - SURGERY PF-AMPUTATE LEG AT THIGH EACH 27591 "$2,655.00 " 960 "$1,858.50 " "$1,327.50 " "$2,124.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315534 PHYSICIAN FEE - SURGERY PF-AMPUTATE LEG AT THIGH EACH 27592 "$1,880.00 " 960 "$1,316.00 " $940.00 "$1,504.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315567 PHYSICIAN FEE - SURGERY PF-AMPUTATE LOWER LEG AT KNEE EACH 27598 "$1,943.00 " 960 "$1,360.10 " $971.50 "$1,554.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313018 PHYSICIAN FEE - SURGERY PF-AMPUTATE METACARPAL BONE EACH 26910 "$2,053.00 " 960 "$1,437.10 " "$1,026.50 " "$1,642.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309669 PHYSICIAN FEE - SURGERY PF-AMPUTATE UPPER ARM&IMPLANT EACH 24931 "$2,567.00 " 960 "$1,796.90 " "$1,283.50 " "$2,053.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308539 PHYSICIAN FEE - SURGERY PF-AMPUTATION AT SHOULDER JT EACH 23920 "$3,096.00 " 960 "$2,167.20 " "$1,548.00 " "$2,476.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311186 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 25909 "$1,892.00 " 960 "$1,324.40 " $946.00 "$1,513.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308547 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 23921 "$1,303.00 " 960 $912.10 $651.50 "$1,042.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309644 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 24925 "$1,573.00 " 960 "$1,101.10 " $786.50 "$1,258.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309651 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 24930 "$2,135.00 " 960 "$1,494.50 " "$1,067.50 " "$1,708.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311178 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 25907 "$1,699.00 " 960 "$1,189.30 " $849.50 "$1,359.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311228 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 25924 "$1,954.00 " 960 "$1,367.80 " $977.00 "$1,563.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311244 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 25929 "$1,655.00 " 960 "$1,158.50 " $827.50 "$1,324.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311251 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 25931 "$2,156.00 " 960 "$1,509.20 " "$1,078.00 " "$1,724.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315542 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 27594 "$1,403.00 " 960 $982.10 $701.50 "$1,122.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315559 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 27596 "$1,988.00 " 960 "$1,391.60 " $994.00 "$1,590.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316730 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 27884 "$1,611.00 " 960 "$1,127.70 " $805.50 "$1,288.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316748 PHYSICIAN FEE - SURGERY PF-AMPUTATION FOLLOW-UP SURG EACH 27886 "$1,808.00 " 960 "$1,265.60 " $904.00 "$1,446.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308521 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF ARM & GIRDLE EACH 23900 "$3,813.00 " 960 "$2,669.10 " "$1,906.50 " "$3,050.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313026 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF FINGER/THUMB EACH 26951 "$1,882.00 " 960 "$1,317.40 " $941.00 "$1,505.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313034 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF FINGER/THUMB EACH 26952 "$1,835.00 " 960 "$1,284.50 " $917.50 "$1,468.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316755 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF FOOT AT ANKLE EACH 27888 "$1,631.00 " 960 "$1,141.70 " $815.50 "$1,304.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316763 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF FOOT AT ANKLE EACH 27889 "$1,781.00 " 960 "$1,246.70 " $890.50 "$1,424.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311152 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF FOREARM EACH 25900 "$1,971.00 " 960 "$1,379.70 " $985.50 "$1,576.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311160 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF FOREARM EACH 25905 "$1,940.00 " 960 "$1,358.00 " $970.00 "$1,552.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311194 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF FOREARM EACH 25915 "$3,219.00 " 960 "$2,253.30 " "$1,609.50 " "$2,575.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311236 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF HAND EACH 25927 "$2,333.00 " 960 "$1,633.10 " "$1,166.50 " "$1,866.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314214 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF LEG AT HIP EACH 27290 "$4,470.00 " 960 "$3,129.00 " "$2,235.00 " "$3,576.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314222 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF LEG AT HIP EACH 27295 "$3,488.00 " 960 "$2,441.60 " "$1,744.00 " "$2,790.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316706 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF LOWER LEG EACH 27880 "$2,526.00 " 960 "$1,768.20 " "$1,263.00 " "$2,020.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316714 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF LOWER LEG EACH 27881 "$2,347.00 " 960 "$1,642.90 " "$1,173.50 " "$1,877.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316722 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF LOWER LEG EACH 27882 "$1,663.00 " 960 "$1,164.10 " $831.50 "$1,330.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318496 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF MIDFOOT EACH 28800 "$1,399.00 " 960 $979.30 $699.50 "$1,119.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318520 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF TOE EACH 28820 $473.00 960 $331.10 $236.50 $378.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309628 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF UPPER ARM EACH 24900 "$2,043.00 " 960 "$1,430.10 " "$1,021.50 " "$1,634.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309636 PHYSICIAN FEE - SURGERY PF-AMPUTATION OF UPPER ARM EACH 24920 "$2,024.00 " 960 "$1,416.80 " "$1,012.00 " "$1,619.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318504 PHYSICIAN FEE - SURGERY PF-AMPUTATION THRU METATARSAL EACH 28805 "$1,886.00 " 960 "$1,320.20 " $943.00 "$1,508.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318512 PHYSICIAN FEE - SURGERY PF-AMPUTATION TOE & METATARSAL EACH 28810 "$1,139.00 " 960 $797.30 $569.50 $911.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348030 PHYSICIAN FEE - SURGERY PF-ANAL SP INF PMP W/REPRG&FIL EACH 62369 $93.00 960 $65.10 $46.50 $74.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339898 PHYSICIAN FEE - SURGERY PF-ANAL/URINARY MUSCLE STUDY EACH 51785 $268.00 960 $187.60 $134.00 $214.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348014 PHYSICIAN FEE - SURGERY PF-ANALYZE IMPL PUMP W/O REPRO EACH 62367 $67.00 960 $46.90 $33.50 $53.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324254 PHYSICIAN FEE - SURGERY PF-ANASTOMOSIS/ARTERY-AORTA EACH 33606 "$4,992.00 " 960 "$3,494.40 " "$2,496.00 " "$3,993.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356553 PHYSICIAN FEE - SURGERY PF-ANES GANGLION STELLATE BI EACH 64510 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356546 PHYSICIAN FEE - SURGERY PF-ANES GANGLION STELLATE LT EACH 64510 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356538 PHYSICIAN FEE - SURGERY PF-ANES GANGLION STELLATE RT EACH 64510 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326432 PHYSICIAN FEE - SURGERY PF-ANGIOSCOPY EACH 35400 $418.00 960 $292.60 $209.00 $334.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319650 PHYSICIAN FEE - SURGERY PF-ANKLE ARTHROSCOPY/SURGERY EACH 29891 "$1,828.00 " 960 "$1,279.60 " $914.00 "$1,462.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319668 PHYSICIAN FEE - SURGERY PF-ANKLE ARTHROSCOPY/SURGERY EACH 29892 "$1,714.00 " 960 "$1,199.80 " $857.00 "$1,371.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319684 PHYSICIAN FEE - SURGERY PF-ANKLE ARTHROSCOPY/SURGERY EACH 29894 "$1,370.00 " 960 $959.00 $685.00 "$1,096.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319692 PHYSICIAN FEE - SURGERY PF-ANKLE ARTHROSCOPY/SURGERY EACH 29895 "$1,249.00 " 960 $874.30 $624.50 $999.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319700 PHYSICIAN FEE - SURGERY PF-ANKLE ARTHROSCOPY/SURGERY EACH 29897 "$1,344.00 " 960 $940.80 $672.00 "$1,075.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319718 PHYSICIAN FEE - SURGERY PF-ANKLE ARTHROSCOPY/SURGERY EACH 29898 "$1,511.00 " 960 "$1,057.70 " $755.50 "$1,208.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319726 PHYSICIAN FEE - SURGERY PF-ANKLE ARTHROSCOPY/SURGERY EACH 29899 "$2,743.00 " 960 "$1,920.10 " "$1,371.50 " "$2,194.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348048 PHYSICIAN FEE - SURGERY PF-ANL SP INF PMP W/REPRG&FIL EACH 62370 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335714 PHYSICIAN FEE - SURGERY PF-ANOCOPY-REMOVE LESION-SNARE EACH 46611 $217.00 960 $151.90 $108.50 $173.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335680 PHYSICIAN FEE - SURGERY PF-ANOSCOPY AND BIOPSY EACH 46606 $205.00 960 $143.50 $102.50 $164.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335672 PHYSICIAN FEE - SURGERY PF-ANOSCOPY AND DILATION EACH 46604 $180.00 960 $126.00 $90.00 $144.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335730 PHYSICIAN FEE - SURGERY PF-ANOSCOPY CONTROL BLEEDING EACH 46614 $174.00 960 $121.80 $87.00 $139.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335698 PHYSICIAN FEE - SURGERY PF-ANOSCOPY REMOVE FOR BODY EACH 46608 $239.00 960 $167.30 $119.50 $191.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335706 PHYSICIAN FEE - SURGERY PF-ANOSCOPY REMOVE LESION EACH 46610 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335722 PHYSICIAN FEE - SURGERY PF-ANOSCOPY REMOVE LESIONS EACH 46612 $270.00 960 $189.00 $135.00 $216.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345184 PHYSICIAN FEE - SURGERY PF-ANTEPARTUM CARE ONLY EACH 59425 "$1,256.00 " 960 $879.20 $628.00 "$1,004.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345192 PHYSICIAN FEE - SURGERY PF-ANTEPARTUM CARE ONLY EACH 59426 "$2,308.00 " 960 "$1,615.60 " "$1,154.00 " "$1,846.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345168 PHYSICIAN FEE - SURGERY PF-ANTEPARTUM MANIPULATION EACH 59412 $299.00 960 $209.30 $149.50 $239.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357718 PHYSICIAN FEE - SURGERY PF-ANUS SURGERY PROCEDURE NOS EACH 46999 $421.00 960 $294.70 $210.50 $336.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325251 PHYSICIAN FEE - SURGERY PF-AORTIC CIRCULATION ASSIST EACH 33970 $981.00 960 $686.70 $490.50 $784.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325269 PHYSICIAN FEE - SURGERY PF-AORTIC CIRCULATION ASSIST EACH 33971 "$1,966.00 " 960 "$1,376.20 " $983.00 "$1,572.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358963 PHYSICIAN FEE - SURGERY PF-AORTIC HEMIARCH GRAFT EACH 33866 "$2,574.00 " 960 "$1,801.80 " "$1,287.00 " "$2,059.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324841 PHYSICIAN FEE - SURGERY PF-AORTIC SUSPENSION EACH 33800 "$2,768.00 " 960 "$1,937.60 " "$1,384.00 " "$2,214.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328073 PHYSICIAN FEE - SURGERY PF-APHERESIS PLASMA EACH 36514 $241.00 960 $168.70 $120.50 $192.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328065 PHYSICIAN FEE - SURGERY PF-APHERESIS PLATELETS EACH 36513 $275.00 960 $192.50 $137.50 $220.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328057 PHYSICIAN FEE - SURGERY PF-APHERESIS RBC EACH 36512 $269.00 960 $188.30 $134.50 $215.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328099 PHYSICIAN FEE - SURGERY PF-APHERESIS SELECTIVE EACH 36516 $236.00 960 $165.20 $118.00 $188.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328040 PHYSICIAN FEE - SURGERY PF-APHERESIS WBC EACH 36511 $283.00 960 $198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334568 PHYSICIAN FEE - SURGERY PF-APPENDECTOMY EACH 44950 "$1,817.00 " 960 "$1,271.90 " $908.50 "$1,453.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334584 PHYSICIAN FEE - SURGERY PF-APPENDECTOMY EACH 44960 "$2,484.00 " 960 "$1,738.80 " "$1,242.00 " "$1,987.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334576 PHYSICIAN FEE - SURGERY PF-APPENDECTOMY ADD-ON EACH 44955 $234.00 960 $163.80 $117.00 $187.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339252 PHYSICIAN FEE - SURGERY PF-APPENDICO-VESICOSTOMY EACH 50845 "$3,323.00 " 960 "$2,326.10 " "$1,661.50 " "$2,658.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319007 PHYSICIAN FEE - SURGERY PF-APPL MULTLAY COMPRS ARM/HND EACH 29584 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318835 PHYSICIAN FEE - SURGERY PF-APPLICATION LONG LEG CAST EACH 29365 $240.00 960 $168.00 $120.00 $192.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318553 PHYSICIAN FEE - SURGERY PF-APPLICATION OF BODY CAST EACH 29000 $581.00 960 $406.70 $290.50 $464.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318595 PHYSICIAN FEE - SURGERY PF-APPLICATION OF BODY CAST EACH 29040 $472.00 960 $330.40 $236.00 $377.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318603 PHYSICIAN FEE - SURGERY PF-APPLICATION OF BODY CAST EACH 29044 $456.00 960 $319.20 $228.00 $364.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318611 PHYSICIAN FEE - SURGERY PF-APPLICATION OF BODY CAST EACH 29046 $512.00 960 $358.40 $256.00 $409.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318629 PHYSICIAN FEE - SURGERY PF-APPLICATION OF FIGURE EIGHT EACH 29049 $191.00 960 $133.70 $95.50 $152.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304272 PHYSICIAN FEE - SURGERY PF-APPLICATION OF HALO EACH 20664 "$2,608.00 " 960 "$1,825.60 " "$1,304.00 " "$2,086.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304249 PHYSICIAN FEE - SURGERY PF-APPLICATION OF HEAD BRACE EACH 20661 "$1,490.00 " 960 "$1,043.00 " $745.00 "$1,192.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304256 PHYSICIAN FEE - SURGERY PF-APPLICATION OF PELVIS BRACE EACH 20662 "$1,432.00 " 960 "$1,002.40 " $716.00 "$1,145.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304264 PHYSICIAN FEE - SURGERY PF-APPLICATION OF THIGH BRACE EACH 20663 "$1,323.00 " 960 $926.10 $661.50 "$1,058.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318645 PHYSICIAN FEE - SURGERY PF-APPLICATION SHOULDER CAST EACH 29058 $256.00 960 $179.20 $128.00 $204.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318637 PHYSICIAN FEE - SURGERY PF-APPLICATION SHOULDER CAST EACH 29055 $377.00 960 $263.90 $188.50 $301.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304314 PHYSICIAN FEE - SURGERY PF-APPLY BONE FIXATION DEVICE EACH 20690 "$1,640.00 " 960 "$1,148.00 " $820.00 "$1,312.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304322 PHYSICIAN FEE - SURGERY PF-APPLY BONE FIXATION DEVICE EACH 20692 "$3,069.00 " 960 "$2,148.30 " "$1,534.50 " "$2,455.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318686 PHYSICIAN FEE - SURGERY PF-APPLY FINGER CAST EACH 29086 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318736 PHYSICIAN FEE - SURGERY PF-APPLY FINGER SPLINT DYNAMIC EACH 29131 $94.00 960 $65.80 $47.00 $75.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318728 PHYSICIAN FEE - SURGERY PF-APPLY FINGER SPLINT STATIC EACH 29130 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318678 PHYSICIAN FEE - SURGERY PF-APPLY HAND/WRIST CAST EACH 29085 $183.00 960 $128.10 $91.50 $146.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318694 PHYSICIAN FEE - SURGERY PF-APPLY LONG ARM SPLINT EACH 29105 $117.00 960 $81.90 $58.50 $93.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318827 PHYSICIAN FEE - SURGERY PF-APPLY LONG LEG CAST BRACE EACH 29358 $283.00 960 $198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318819 PHYSICIAN FEE - SURGERY PF-APPLY LONG LEG CAST-WALKING EACH 29355 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318918 PHYSICIAN FEE - SURGERY PF-APPLY LOWER LEG SPLINT EACH 29515 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318975 PHYSICIAN FEE - SURGERY PF-APPLY MULTLAY COMPRS LWR LG EACH 29581 $67.00 960 $46.90 $33.50 $53.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349582 PHYSICIAN FEE - SURGERY PF-APPLY NEUROSTIMULATOR EACH 97014 $32.00 960 $22.40 $16.00 $25.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324338 PHYSICIAN FEE - SURGERY PF-APPLY R&L PULM ART BANDS EACH 33620 "$4,631.00 " 960 "$3,241.70 " "$2,315.50 " "$3,704.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304231 PHYSICIAN FEE - SURGERY PF-APPLY REM FIXATION DEVICE EACH 20660 $702.00 960 $491.40 $351.00 $561.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318884 PHYSICIAN FEE - SURGERY PF-APPLY RIGID LEG CAST EACH 29445 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318710 PHYSICIAN FEE - SURGERY PF-APPLY SH ARM SPLINT DYNAMIC EACH 29126 $133.00 960 $93.10 $66.50 $106.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318702 PHYSICIAN FEE - SURGERY PF-APPLY SH ARM SPLINT STATIC EACH 29125 $109.00 960 $76.30 $54.50 $87.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318850 PHYSICIAN FEE - SURGERY PF-APPLY SH LEG CAST - WALKING EACH 29425 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318843 PHYSICIAN FEE - SURGERY PF-APPLY SHORT LEG CAST EACH 29405 $158.00 960 $110.60 $79.00 $126.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347230 PHYSICIAN FEE - SURGERY PF-APPLY SRS HEADFRAME ADD-ON EACH 61800 $453.00 960 $317.10 $226.50 $362.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355126 PHYSICIAN FEE - SURGERY PF-AQUEOUS SHUNT EYE W/O GRAFT EACH 66179 "$2,764.00 " 960 "$1,934.80 " "$1,382.00 " "$2,211.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308968 PHYSICIAN FEE - SURGERY PF-ARM TENDON LENGTHENING EACH 24305 "$1,593.00 " 960 "$1,115.10 " $796.50 "$1,274.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327208 PHYSICIAN FEE - SURGERY PF-ARTERIAL TRANSPOSITION EACH 35691 "$2,673.00 " 960 "$1,871.10 " "$1,336.50 " "$2,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327216 PHYSICIAN FEE - SURGERY PF-ARTERIAL TRANSPOSITION EACH 35693 "$2,360.00 " 960 "$1,652.00 " "$1,180.00 " "$1,888.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327224 PHYSICIAN FEE - SURGERY PF-ARTERIAL TRANSPOSITION EACH 35694 "$2,793.00 " 960 "$1,955.10 " "$1,396.50 " "$2,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327232 PHYSICIAN FEE - SURGERY PF-ARTERIAL TRANSPOSITION EACH 35695 "$2,899.00 " 960 "$2,029.30 " "$1,449.50 " "$2,319.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326531 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35501 "$4,131.00 " 960 "$2,891.70 " "$2,065.50 " "$3,304.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326549 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35506 "$3,604.00 " 960 "$2,522.80 " "$1,802.00 " "$2,883.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326556 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35508 "$3,758.00 " 960 "$2,630.60 " "$1,879.00 " "$3,006.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326564 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35509 "$3,992.00 " 960 "$2,794.40 " "$1,996.00 " "$3,193.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326572 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35510 "$3,480.00 " 960 "$2,436.00 " "$1,740.00 " "$2,784.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326580 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35511 "$3,170.00 " 960 "$2,219.00 " "$1,585.00 " "$2,536.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326598 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35512 "$3,412.00 " 960 "$2,388.40 " "$1,706.00 " "$2,729.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326606 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35515 "$3,758.00 " 960 "$2,630.60 " "$1,879.00 " "$3,006.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326614 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35516 "$3,453.00 " 960 "$2,417.10 " "$1,726.50 " "$2,762.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326622 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35518 "$3,231.00 " 960 "$2,261.70 " "$1,615.50 " "$2,584.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326630 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35521 "$3,473.00 " 960 "$2,431.10 " "$1,736.50 " "$2,778.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326648 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35522 "$3,308.00 " 960 "$2,315.60 " "$1,654.00 " "$2,646.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326655 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35523 "$3,477.00 " 960 "$2,433.90 " "$1,738.50 " "$2,781.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326663 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35525 "$3,188.00 " 960 "$2,231.60 " "$1,594.00 " "$2,550.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326671 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35526 "$4,802.00 " 960 "$3,361.40 " "$2,401.00 " "$3,841.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326689 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35531 "$5,524.00 " 960 "$3,866.80 " "$2,762.00 " "$4,419.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326697 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35533 "$4,267.00 " 960 "$2,986.90 " "$2,133.50 " "$3,413.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326705 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35535 "$5,390.00 " 960 "$3,773.00 " "$2,695.00 " "$4,312.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326713 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35536 "$4,782.00 " 960 "$3,347.40 " "$2,391.00 " "$3,825.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326721 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35537 "$5,907.00 " 960 "$4,134.90 " "$2,953.50 " "$4,725.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326739 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35538 "$6,615.00 " 960 "$4,630.50 " "$3,307.50 " "$5,292.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326747 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35539 "$6,209.00 " 960 "$4,346.30 " "$3,104.50 " "$4,967.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326754 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35540 "$6,921.00 " 960 "$4,844.70 " "$3,460.50 " "$5,536.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326762 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35556 "$3,919.00 " 960 "$2,743.30 " "$1,959.50 " "$3,135.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326770 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35558 "$3,477.00 " 960 "$2,433.90 " "$1,738.50 " "$2,781.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326788 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35560 "$4,826.00 " 960 "$3,378.20 " "$2,413.00 " "$3,860.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326796 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35563 "$3,746.00 " 960 "$2,622.20 " "$1,873.00 " "$2,996.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326804 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35565 "$3,689.00 " 960 "$2,582.30 " "$1,844.50 " "$2,951.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326812 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35566 "$4,683.00 " 960 "$3,278.10 " "$2,341.50 " "$3,746.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326820 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35570 "$4,171.00 " 960 "$2,919.70 " "$2,085.50 " "$3,336.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326838 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35571 "$3,727.00 " 960 "$2,608.90 " "$1,863.50 " "$2,981.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326895 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35601 "$3,948.00 " 960 "$2,763.60 " "$1,974.00 " "$3,158.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326903 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35606 "$3,310.00 " 960 "$2,317.00 " "$1,655.00 " "$2,648.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326911 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35612 "$2,956.00 " 960 "$2,069.20 " "$1,478.00 " "$2,364.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326929 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35616 "$3,117.00 " 960 "$2,181.90 " "$1,558.50 " "$2,493.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326937 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35621 "$3,085.00 " 960 "$2,159.50 " "$1,542.50 " "$2,468.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326952 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35626 "$4,437.00 " 960 "$3,105.90 " "$2,218.50 " "$3,549.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326960 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35631 "$5,217.00 " 960 "$3,651.90 " "$2,608.50 " "$4,173.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326986 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35633 "$5,601.00 " 960 "$3,920.70 " "$2,800.50 " "$4,480.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326994 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35634 "$5,006.00 " 960 "$3,504.20 " "$2,503.00 " "$4,004.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327000 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35636 "$4,514.00 " 960 "$3,159.80 " "$2,257.00 " "$3,611.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327018 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35637 "$4,693.00 " 960 "$3,285.10 " "$2,346.50 " "$3,754.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327026 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35638 "$4,885.00 " 960 "$3,419.50 " "$2,442.50 " "$3,908.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327034 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35642 "$2,788.00 " 960 "$1,951.60 " "$1,394.00 " "$2,230.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327042 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35645 "$2,677.00 " 960 "$1,873.90 " "$1,338.50 " "$2,141.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327059 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35646 "$4,800.00 " 960 "$3,360.00 " "$2,400.00 " "$3,840.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327067 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35647 "$4,363.00 " 960 "$3,054.10 " "$2,181.50 " "$3,490.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327075 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35650 "$2,889.00 " 960 "$2,022.30 " "$1,444.50 " "$2,311.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327083 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35654 "$3,839.00 " 960 "$2,687.30 " "$1,919.50 " "$3,071.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327091 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35656 "$3,017.00 " 960 "$2,111.90 " "$1,508.50 " "$2,413.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327109 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35661 "$3,040.00 " 960 "$2,128.00 " "$1,520.00 " "$2,432.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327117 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35663 "$3,448.00 " 960 "$2,413.60 " "$1,724.00 " "$2,758.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327125 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35665 "$3,297.00 " 960 "$2,307.90 " "$1,648.50 " "$2,637.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327133 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35666 "$3,606.00 " 960 "$2,524.20 " "$1,803.00 " "$2,884.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327141 PHYSICIAN FEE - SURGERY PF-ARTERY BYPASS GRAFT EACH 35671 "$3,173.00 " 960 "$2,221.10 " "$1,586.50 " "$2,538.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354905 PHYSICIAN FEE - SURGERY PF-ARTERY EXPOS/GRAFT ARTERY EACH 33987 $579.00 960 $405.30 $289.50 $463.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328610 PHYSICIAN FEE - SURGERY PF-ARTERY TO VEIN SHUNT EACH 36835 "$1,347.00 " 960 $942.90 $673.50 "$1,077.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325087 PHYSICIAN FEE - SURGERY PF-ARTERY TRANSPOSE/ENDOV TAA EACH 33889 "$2,244.00 " 960 "$1,570.80 " "$1,122.00 " "$1,795.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328560 PHYSICIAN FEE - SURGERY PF-ARTERY-VEIN AUTOGRAFT EACH 36825 "$2,222.00 " 960 "$1,555.40 " "$1,111.00 " "$1,777.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328578 PHYSICIAN FEE - SURGERY PF-ARTERY-VEIN NONAUTOGRAFT EACH 36830 "$1,866.00 " 960 "$1,306.20 " $933.00 "$1,492.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355266 PHYSICIAN FEE - SURGERY PF-ARTHRO LOOSE BODY + CHOND EACH G0289 $236.00 960 $165.20 $118.00 $188.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357536 PHYSICIAN FEE - SURGERY PF-ARTHRO LOOSE BODY + CHOND EACH G0289 $236.00 960 $165.20 $118.00 $188.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354608 PHYSICIAN FEE - SURGERY PF-ARTHRODESIS SACROILIAC JT EACH 27279 "$2,206.00 " 960 "$1,544.20 " "$1,103.00 " "$1,764.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319213 PHYSICIAN FEE - SURGERY PF-ARTHROSC ROTATOR CUFF REPR EACH 29827 "$2,932.00 " 960 "$2,052.40 " "$1,466.00 " "$2,345.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319221 PHYSICIAN FEE - SURGERY PF-ARTHROSCPY BICEPS TENODESIS EACH 29828 "$2,515.00 " 960 "$1,760.50 " "$1,257.50 " "$2,012.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316870 PHYSICIAN FEE - SURGERY PF-ARTHROTOMY INTERTAR/TARS JT EACH 28020 $976.00 960 $683.20 $488.00 $780.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316987 PHYSICIAN FEE - SURGERY PF-ARTHROTOMY W BX METATAR JNT EACH 28052 $670.00 960 $469.00 $335.00 $536.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316979 PHYSICIAN FEE - SURGERY PF-ARTHROTOMY W/BX INT/TAR JT EACH 28050 $731.00 960 $511.70 $365.50 $584.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344104 PHYSICIAN FEE - SURGERY PF-ARTIFICIAL INSEMINATION EACH 58322 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344096 PHYSICIAN FEE - SURGERY PF-ARTIFICIAL INSEMINATION EACH 58321 $133.00 960 $93.10 $66.50 $106.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361561 PHYSICIAN FEE - SURGERY PF-AS-AORT GRF F/DS OTH/TH DSJ EACH 33859 "$6,808.00 " 960 "$4,765.60 " "$3,404.00 " "$5,446.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324981 PHYSICIAN FEE - SURGERY PF-ASCENDING AORTIC GRAFT EACH 33863 "$8,789.00 " 960 "$6,152.30 " "$4,394.50 " "$7,031.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324999 PHYSICIAN FEE - SURGERY PF-ASCENDING AORTIC GRAFT EACH 33864 "$8,985.00 " 960 "$6,289.50 " "$4,492.50 " "$7,188.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345614 PHYSICIAN FEE - SURGERY PF-ASPIR/INJ THYROID CYST EACH 60300 $127.00 960 $88.90 $63.50 $101.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322258 PHYSICIAN FEE - SURGERY PF-ASPIRATE PLEURA W/O IMAGING EACH 32554 $234.00 960 $163.80 $117.00 $187.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339963 PHYSICIAN FEE - SURGERY PF-ATTACH BLADDER/URETHRA EACH 51840 "$1,859.00 " 960 "$1,301.30 " $929.50 "$1,487.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339971 PHYSICIAN FEE - SURGERY PF-ATTACH BLADDER/URETHRA EACH 51841 "$2,136.00 " 960 "$1,495.20 " "$1,068.00 " "$1,708.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350903 PHYSICIAN FEE - SURGERY PF-ATTACH OCULAR IMPLANT EACH 65140 "$2,373.00 " 960 "$1,661.10 " "$1,186.50 " "$1,898.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345309 PHYSICIAN FEE - SURGERY PF-ATTEMPTED VBAC AFTER CARE EACH 59622 "$4,059.00 " 960 "$2,841.30 " "$2,029.50 " "$3,247.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345291 PHYSICIAN FEE - SURGERY PF-ATTEMPTED VBAC DELIV ONLY EACH 59620 "$2,756.00 " 960 "$1,929.20 " "$1,378.00 " "$2,204.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345283 PHYSICIAN FEE - SURGERY PF-ATTEMPTED VBAC DELIVERY EACH 59618 "$7,857.00 " 960 "$5,499.90 " "$3,928.50 " "$6,285.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305683 PHYSICIAN FEE - SURGERY PF-AUGMENTATION CHEEK BONE EACH 21270 "$2,030.00 " 960 "$1,421.00 " "$1,015.00 " "$1,624.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305469 PHYSICIAN FEE - SURGERY PF-AUGMENTATION FACIAL BONES EACH 21208 "$1,927.00 " 960 "$1,348.90 " $963.50 "$1,541.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305139 PHYSICIAN FEE - SURGERY PF-AUGMENTATION LOWER JAW BONE EACH 21125 "$1,748.00 " 960 "$1,223.60 " $874.00 "$1,398.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305147 PHYSICIAN FEE - SURGERY PF-AUGMENTATION LOWER JAW BONE EACH 21127 "$2,029.00 " 960 "$1,420.30 " "$1,014.50 " "$1,623.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319445 PHYSICIAN FEE - SURGERY PF-AUTGRFT IMPLNT KNEE W/SCOPE EACH 29866 "$2,896.00 " 960 "$2,027.20 " "$1,448.00 " "$2,316.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314743 PHYSICIAN FEE - SURGERY PF-AUTOCHONDRCYTE IMPLANT KNEE EACH 27412 "$4,535.00 " 960 "$3,174.50 " "$2,267.50 " "$3,628.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345655 PHYSICIAN FEE - SURGERY PF-AUTOTRANSPLANT PARATHYROID EACH 60512 $673.00 960 $471.10 $336.50 $538.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328602 PHYSICIAN FEE - SURGERY PF-AV FISTULA REVISION EACH 36833 "$2,260.00 " 960 "$1,582.00 " "$1,130.00 " "$1,808.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328594 PHYSICIAN FEE - SURGERY PF-AV FISTULA REVISION OPEN EACH 36832 "$2,116.00 " 960 "$1,481.20 " "$1,058.00 " "$1,692.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328529 PHYSICIAN FEE - SURGERY PF-AV FUSE UPPR ARM BASILIC EACH 36819 "$2,049.00 " 960 "$1,434.30 " "$1,024.50 " "$1,639.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328511 PHYSICIAN FEE - SURGERY PF-AV FUSE UPPR ARM CEPHALIC EACH 36818 "$1,929.00 " 960 "$1,350.30 " $964.50 "$1,543.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328545 PHYSICIAN FEE - SURGERY PF-AV FUSION DIRECT ANY SITE EACH 36821 "$1,847.00 " 960 "$1,292.90 " $923.50 "$1,477.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328537 PHYSICIAN FEE - SURGERY PF-AV FUSION/FOREARM VEIN EACH 36820 "$2,034.00 " 960 "$1,423.80 " "$1,017.00 " "$1,627.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336506 PHYSICIAN FEE - SURGERY PF-BILE DUCT ENDOSCOPY ADD-ON EACH 47550 $461.00 960 $322.70 $230.50 $368.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336696 PHYSICIAN FEE - SURGERY PF-BILE DUCT REVISION EACH 47701 "$4,925.00 " 960 "$3,447.50 " "$2,462.50 " "$3,940.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336514 PHYSICIAN FEE - SURGERY PF-BILIARY ENDOSCOPY THRU SKIN EACH 47552 $735.00 960 $514.50 $367.50 $588.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336522 PHYSICIAN FEE - SURGERY PF-BILIARY ENDOSCOPY THRU SKIN EACH 47553 $738.00 960 $516.60 $369.00 $590.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336530 PHYSICIAN FEE - SURGERY PF-BILIARY ENDOSCOPY THRU SKIN EACH 47554 "$1,192.00 " 960 $834.40 $596.00 $953.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336548 PHYSICIAN FEE - SURGERY PF-BILIARY ENDOSCOPY THRU SKIN EACH 47555 $880.00 960 $616.00 $440.00 $704.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336555 PHYSICIAN FEE - SURGERY PF-BILIARY ENDOSCOPY THRU SKIN EACH 47556 $998.00 960 $698.60 $499.00 $798.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322092 PHYSICIAN FEE - SURGERY PF-BILOBECTOMY EACH 32482 "$4,424.00 " 960 "$3,096.80 " "$2,212.00 " "$3,539.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308604 PHYSICIAN FEE - SURGERY PF-BIOPSY ARM/ELB SOFT TISSUE EACH 24065 $437.00 960 $305.90 $218.50 $349.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308612 PHYSICIAN FEE - SURGERY PF-BIOPSY ARM/ELB SOFT TISSUE EACH 24066 "$1,168.00 " 960 $817.60 $584.00 $934.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308687 PHYSICIAN FEE - SURGERY PF-BIOPSY ELBOW JOINT LINING EACH 24100 "$1,163.00 " 960 $814.10 $581.50 $930.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353568 PHYSICIAN FEE - SURGERY PF-BIOPSY EXTERNAL EAR CANAL EACH 69105 $170.00 960 $119.00 $85.00 $136.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352453 PHYSICIAN FEE - SURGERY PF-BIOPSY EYE MUSCLE EACH 67346 $493.00 960 $345.10 $246.50 $394.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311426 PHYSICIAN FEE - SURGERY PF-BIOPSY FINGER JOINT LINING EACH 26105 $942.00 960 $659.40 $471.00 $753.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311434 PHYSICIAN FEE - SURGERY PF-BIOPSY FINGER JOINT LINING EACH 26110 $894.00 960 $625.80 $447.00 $715.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309800 PHYSICIAN FEE - SURGERY PF-BIOPSY FOREARM SOFT TISSUES EACH 25066 "$1,006.00 " 960 $704.20 $503.00 $804.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309792 PHYSICIAN FEE - SURGERY PF-BIOPSY FOREARM SOFT TISSUES EACH 25065 $423.00 960 $296.10 $211.50 $338.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311418 PHYSICIAN FEE - SURGERY PF-BIOPSY HAND JOINT LINING EACH 26100 $938.00 960 $656.60 $469.00 $750.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314362 PHYSICIAN FEE - SURGERY PF-BIOPSY KNEE JOINT LINING EACH 27330 "$1,170.00 " 960 $819.00 $585.00 $936.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315674 PHYSICIAN FEE - SURGERY PF-BIOPSY LOW LEG SOFT TISSUE EACH 27613 $433.00 960 $303.10 $216.50 $346.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315682 PHYSICIAN FEE - SURGERY PF-BIOPSY LOW LEG TISSUE DEEP EACH 27614 "$1,128.00 " 960 $789.60 $564.00 $902.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300973 PHYSICIAN FEE - SURGERY PF-BIOPSY NAIL UNIT EACH 11755 $158.00 960 $110.60 $79.00 $126.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333594 PHYSICIAN FEE - SURGERY PF-BIOPSY OF BOWEL EACH 44100 $281.00 960 $196.70 $140.50 $224.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303449 PHYSICIAN FEE - SURGERY PF-BIOPSY OF BREAST OPEN EACH 19101 $625.00 960 $437.50 $312.50 $500.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343643 PHYSICIAN FEE - SURGERY PF-BIOPSY OF CERVIX EACH 57500 $204.00 960 $142.80 $102.00 $163.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343601 PHYSICIAN FEE - SURGERY PF-BIOPSY OF CERVIX W/SCOPE EACH 57455 $297.00 960 $207.90 $148.50 $237.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342132 PHYSICIAN FEE - SURGERY PF-BIOPSY OF EPIDIDYMIS EACH 54800 $333.00 960 $233.10 $166.50 $266.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353550 PHYSICIAN FEE - SURGERY PF-BIOPSY OF EXTERNAL EAR EACH 69100 $122.00 960 $85.40 $61.00 $97.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352701 PHYSICIAN FEE - SURGERY PF-BIOPSY OF EYELID EACH 67810 $176.00 960 $123.20 $88.00 $140.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353105 PHYSICIAN FEE - SURGERY PF-BIOPSY OF EYELID LINING EACH 68100 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330533 PHYSICIAN FEE - SURGERY PF-BIOPSY OF FLOOR OF MOUTH EACH 41108 $242.00 960 $169.40 $121.00 $193.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313265 PHYSICIAN FEE - SURGERY PF-BIOPSY OF HIP JOINT EACH 27052 "$1,598.00 " 960 "$1,118.60 " $799.00 "$1,278.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330046 PHYSICIAN FEE - SURGERY PF-BIOPSY OF LIP EACH 40490 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330244 PHYSICIAN FEE - SURGERY PF-BIOPSY OF MOUTH LESION EACH 40808 $235.00 960 $164.50 $117.50 $188.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306335 PHYSICIAN FEE - SURGERY PF-BIOPSY OF NECK/CHEST EACH 21550 $417.00 960 $291.90 $208.50 $333.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350341 PHYSICIAN FEE - SURGERY PF-BIOPSY OF NERVE EACH 64795 $558.00 960 $390.60 $279.00 $446.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344682 PHYSICIAN FEE - SURGERY PF-BIOPSY OF OVARY(S) EACH 58900 "$1,193.00 " 960 $835.10 $596.50 $954.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336886 PHYSICIAN FEE - SURGERY PF-BIOPSY OF PANCREAS OPEN EACH 48100 "$2,520.00 " 960 "$1,764.00 " "$1,260.00 " "$2,016.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341357 PHYSICIAN FEE - SURGERY PF-BIOPSY OF PENIS EACH 54100 $319.00 960 $223.30 $159.50 $255.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341365 PHYSICIAN FEE - SURGERY PF-BIOPSY OF PENIS EACH 54105 $566.00 960 $396.20 $283.00 $452.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334634 PHYSICIAN FEE - SURGERY PF-BIOPSY OF RECTUM EACH 45100 $825.00 960 $577.50 $412.50 $660.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313257 PHYSICIAN FEE - SURGERY PF-BIOPSY OF SACROILIAC JOINT EACH 27050 "$1,119.00 " 960 $783.30 $559.50 $895.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307697 PHYSICIAN FEE - SURGERY PF-BIOPSY OF SHOULDER JOINT EACH 23100 "$1,397.00 " 960 $977.90 $698.50 "$1,117.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313182 PHYSICIAN FEE - SURGERY PF-BIOPSY OF SOFT TISSUES EACH 27040 $536.00 960 $375.20 $268.00 $428.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313190 PHYSICIAN FEE - SURGERY PF-BIOPSY OF SOFT TISSUES EACH 27041 "$1,948.00 " 960 "$1,363.60 " $974.00 "$1,558.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332935 PHYSICIAN FEE - SURGERY PF-BIOPSY OF STOMACH EACH 43605 "$2,360.00 " 960 "$1,652.00 " "$1,180.00 " "$1,888.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353337 PHYSICIAN FEE - SURGERY PF-BIOPSY OF TEAR SAC EACH 68525 $664.00 960 $464.80 $332.00 $531.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341944 PHYSICIAN FEE - SURGERY PF-BIOPSY OF TESTIS EACH 54500 $198.00 960 $138.60 $99.00 $158.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331424 PHYSICIAN FEE - SURGERY PF-BIOPSY OF THROAT EACH 42800 $313.00 960 $219.10 $156.50 $250.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330525 PHYSICIAN FEE - SURGERY PF-BIOPSY OF TONGUE EACH 41105 $293.00 960 $205.10 $146.50 $234.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331432 PHYSICIAN FEE - SURGERY PF-BIOPSY OF UPPER NOSE/THROAT EACH 42804 $327.00 960 $228.90 $163.50 $261.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331440 PHYSICIAN FEE - SURGERY PF-BIOPSY OF UPPER NOSE/THROAT EACH 42806 $378.00 960 $264.60 $189.00 $302.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340789 PHYSICIAN FEE - SURGERY PF-BIOPSY OF URETHRA EACH 53200 $380.00 960 $266.00 $190.00 $304.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343023 PHYSICIAN FEE - SURGERY PF-BIOPSY OF VAGINA EACH 57105 $394.00 960 $275.80 $197.00 $315.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342769 PHYSICIAN FEE - SURGERY PF-BIOPSY OF VULVA/PERINEUM EACH 56605 $162.00 960 $113.40 $81.00 $129.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309883 PHYSICIAN FEE - SURGERY PF-BIOPSY OF WRIST JOINT EACH 25100 $966.00 960 $676.20 $483.00 $772.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307614 PHYSICIAN FEE - SURGERY PF-BIOPSY SHOULDER TISSUES EACH 23065 $430.00 960 $301.00 $215.00 $344.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307622 PHYSICIAN FEE - SURGERY PF-BIOPSY SHOULDER TISSUES EACH 23066 "$1,014.00 " 960 $709.80 $507.00 $811.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306590 PHYSICIAN FEE - SURGERY PF-BIOPSY SOFT TISSUE OF BACK EACH 21920 $416.00 960 $291.20 $208.00 $332.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306608 PHYSICIAN FEE - SURGERY PF-BIOPSY SOFT TISSUE OF BACK EACH 21925 "$1,046.00 " 960 $732.20 $523.00 $836.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314297 PHYSICIAN FEE - SURGERY PF-BIOPSY THIGH SOFT TISSUES EACH 27323 $469.00 960 $328.30 $234.50 $375.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314305 PHYSICIAN FEE - SURGERY PF-BIOPSY THIGH SOFT TISSUES EACH 27324 "$1,139.00 " 960 $797.30 $569.50 $911.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348725 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63275 "$5,364.00 " 960 "$3,754.80 " "$2,682.00 " "$4,291.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348733 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63276 "$5,333.00 " 960 "$3,733.10 " "$2,666.50 " "$4,266.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348741 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63277 "$4,603.00 " 960 "$3,222.10 " "$2,301.50 " "$3,682.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348758 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63278 "$4,802.00 " 960 "$3,361.40 " "$2,401.00 " "$3,841.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348766 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63280 "$6,387.00 " 960 "$4,470.90 " "$3,193.50 " "$5,109.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348774 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63281 "$6,331.00 " 960 "$4,431.70 " "$3,165.50 " "$5,064.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348790 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63283 "$5,740.00 " 960 "$4,018.00 " "$2,870.00 " "$4,592.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348808 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63285 "$7,900.00 " 960 "$5,530.00 " "$3,950.00 " "$6,320.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348816 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63286 "$7,749.00 " 960 "$5,424.30 " "$3,874.50 " "$6,199.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348824 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63287 "$8,288.00 " 960 "$5,801.60 " "$4,144.00 " "$6,630.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348832 PHYSICIAN FEE - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63290 "$5,649.00 " 960 "$3,954.30 " "$2,824.50 " "$4,519.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329634 PHYSICIAN FEE - SURGERY PF-BIOPSY/REMOVAL LYMPH NODES EACH 38500 $714.00 960 $499.80 $357.00 $571.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329659 PHYSICIAN FEE - SURGERY PF-BIOPSY/REMOVAL LYMPH NODES EACH 38510 "$1,150.00 " 960 $805.00 $575.00 $920.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329667 PHYSICIAN FEE - SURGERY PF-BIOPSY/REMOVAL LYMPH NODES EACH 38520 "$1,293.00 " 960 $905.10 $646.50 "$1,034.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329675 PHYSICIAN FEE - SURGERY PF-BIOPSY/REMOVAL LYMPH NODES EACH 38525 "$1,240.00 " 960 $868.00 $620.00 $992.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329683 PHYSICIAN FEE - SURGERY PF-BIOPSY/REMOVAL LYMPH NODES EACH 38530 "$1,561.00 " 960 "$1,092.70 " $780.50 "$1,248.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327836 PHYSICIAN FEE - SURGERY PF-BL DRAW < 3 YRS FEM/JUGULAR EACH 36400 $48.00 960 $33.60 $24.00 $38.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327851 PHYSICIAN FEE - SURGERY PF-BL DRAW < 3 YRS OTHER VEIN EACH 36406 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327844 PHYSICIAN FEE - SURGERY PF-BL DRAW < 3 YRS SCALP VEIN EACH 36405 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327919 PHYSICIAN FEE - SURGERY PF-BL EXCHANGE/TRANSFUSE NB EACH 36450 $437.00 960 $305.90 $218.50 $349.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327901 PHYSICIAN FEE - SURGERY PF-BL PUSH TRANSFUSE 2 YR OR < EACH 36440 $129.00 960 $90.30 $64.50 $103.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327893 PHYSICIAN FEE - SURGERY PF-BLOOD TRANSFUSION SERVICE EACH 36430 $109.00 960 $76.30 $54.50 $87.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357486 PHYSICIAN FEE - SURGERY PF-BLOOD/LYMPH SYSTEM NOS PROC EACH 38999 $409.00 960 $286.30 $204.50 $327.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357726 PHYSICIAN FEE - SURGERY PF-BONE ALGRFT MORSEL ADD-ON EACH 20930 $504.00 960 $352.80 $252.00 $403.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304017 PHYSICIAN FEE - SURGERY PF-BONE BIOPSY EXCISIONAL EACH 20240 $372.00 960 $260.40 $186.00 $297.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304025 PHYSICIAN FEE - SURGERY PF-BONE BIOPSY EXCISIONAL EACH 20245 $937.00 960 $655.90 $468.50 $749.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303993 PHYSICIAN FEE - SURGERY PF-BONE BIOPSY TROCAR/NEEDLE EACH 20220 $227.00 960 $158.90 $113.50 $181.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304009 PHYSICIAN FEE - SURGERY PF-BONE BIOPSY TROCAR/NEEDLE EACH 20225 $337.00 960 $235.90 $168.50 $269.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358435 PHYSICIAN FEE - SURGERY PF-BONE MARROW ASPIR BONE GRFG EACH 20939 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329493 PHYSICIAN FEE - SURGERY PF-BONE MARROW ASPIRATION EACH 38220 $174.00 960 $121.80 $87.00 $139.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329519 PHYSICIAN FEE - SURGERY PF-BONE MARROW COLLECTION EACH 38230 $561.00 960 $392.70 $280.50 $448.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329527 PHYSICIAN FEE - SURGERY PF-BONE MARROW HARVEST AUTOLOG EACH 38232 $507.00 960 $354.90 $253.50 $405.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329535 PHYSICIAN FEE - SURGERY PF-BONE MARROW/STEM TRANSPLANT EACH 38240 $616.00 960 $431.20 $308.00 $492.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329543 PHYSICIAN FEE - SURGERY PF-BONE MARROW/STEM TRANSPLANT EACH 38241 $456.00 960 $319.20 $228.00 $364.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304645 PHYSICIAN FEE - SURGERY PF-BONE/SKIN GRAFT GREAT TOE EACH 20973 "$8,254.00 " 960 "$5,777.80 " "$4,127.00 " "$6,603.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304629 PHYSICIAN FEE - SURGERY PF-BONE/SKIN GRAFT ILIAC CREST EACH 20970 "$7,832.00 " 960 "$5,482.40 " "$3,916.00 " "$6,265.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304637 PHYSICIAN FEE - SURGERY PF-BONE/SKIN GRAFT METATARSAL EACH 20972 "$7,811.00 " 960 "$5,467.70 " "$3,905.50 " "$6,248.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304611 PHYSICIAN FEE - SURGERY PF-BONE/SKIN GRAFT MICROVASC EACH 20969 "$7,293.00 " 960 "$5,105.10 " "$3,646.50 " "$5,834.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333685 PHYSICIAN FEE - SURGERY PF-BOWEL TO BOWEL FUSION EACH 44130 "$3,702.00 " 960 "$2,591.40 " "$1,851.00 " "$2,961.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346992 PHYSICIAN FEE - SURGERY PF-BRAIN ANEURYSM REPR COMPLX EACH 61697 "$12,762.00 " 960 "$8,933.40 " "$6,381.00 " "$10,209.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347008 PHYSICIAN FEE - SURGERY PF-BRAIN ANEURYSM REPR COMPLX EACH 61698 "$13,987.00 " 960 "$9,790.90 " "$6,993.50 " "$11,189.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347016 PHYSICIAN FEE - SURGERY PF-BRAIN ANEURYSM REPR SIMPLE EACH 61700 "$10,296.00 " 960 "$7,207.20 " "$5,148.00 " "$8,236.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347115 PHYSICIAN FEE - SURGERY PF-BRAIN BIOPSY W/CT/MR GUIDE EACH 61751 "$4,164.00 " 960 "$2,914.80 " "$2,082.00 " "$3,331.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347628 PHYSICIAN FEE - SURGERY PF-BRAIN CAVITY SHUNT W/SCOPE EACH 62201 "$3,635.00 " 960 "$2,544.50 " "$1,817.50 " "$2,908.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303803 PHYSICIAN FEE - SURGERY PF-BREAST RECONSTR W/LAT FLAP EACH 19361 "$4,234.00 " 960 "$2,963.80 " "$2,117.00 " "$3,387.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303779 PHYSICIAN FEE - SURGERY PF-BREAST RECONSTRUCTION EACH 19350 "$1,826.00 " 960 "$1,278.20 " $913.00 "$1,460.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303795 PHYSICIAN FEE - SURGERY PF-BREAST RECONSTRUCTION EACH 19357 "$3,132.00 " 960 "$2,192.40 " "$1,566.00 " "$2,505.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303811 PHYSICIAN FEE - SURGERY PF-BREAST RECONSTRUCTION EACH 19364 "$7,400.00 " 960 "$5,180.00 " "$3,700.00 " "$5,920.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303837 PHYSICIAN FEE - SURGERY PF-BREAST RECONSTRUCTION EACH 19367 "$4,806.00 " 960 "$3,364.20 " "$2,403.00 " "$3,844.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303845 PHYSICIAN FEE - SURGERY PF-BREAST RECONSTRUCTION EACH 19368 "$5,894.00 " 960 "$4,125.80 " "$2,947.00 " "$4,715.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303852 PHYSICIAN FEE - SURGERY PF-BREAST RECONSTRUCTION EACH 19369 "$5,475.00 " 960 "$3,832.50 " "$2,737.50 " "$4,380.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357809 PHYSICIAN FEE - SURGERY PF-BRONCH EBUS IVNTJ PERPH LES EACH 31654 $173.00 960 $121.10 $86.50 $138.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357577 PHYSICIAN FEE - SURGERY PF-BRONCH EBUS SAMPLG 1/2 NODE EACH 31652 $569.00 960 $398.30 $284.50 $455.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357585 PHYSICIAN FEE - SURGERY PF-BRONCH EBUS SAMPLG 3/> NODE EACH 31653 $632.00 960 $442.40 $316.00 $505.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321631 PHYSICIAN FEE - SURGERY PF-BRONCH THERMOPLST 2/> LOBES EACH 31661 $513.00 960 $359.10 $256.50 $410.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321623 PHYSICIAN FEE - SURGERY PF-BRONCH THERMOPLSTY 1 LOBE EACH 31660 $486.00 960 $340.20 $243.00 $388.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321482 PHYSICIAN FEE - SURGERY PF-BRONCH W/BALLOON OCCLUSION EACH 31634 $487.00 960 $340.90 $243.50 $389.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321649 PHYSICIAN FEE - SURGERY PF-BRONCHIAL BRUSH BIOPSY EACH 31717 $273.00 960 $191.10 $136.50 $218.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321599 PHYSICIAN FEE - SURGERY PF-BRONCHIAL VALVE ADDL INSERT EACH 31648 $512.00 960 $358.40 $256.00 $409.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321581 PHYSICIAN FEE - SURGERY PF-BRONCHIAL VALVE INIT INSERT EACH 31647 $529.00 960 $370.30 $264.50 $423.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321615 PHYSICIAN FEE - SURGERY PF-BRONCHIAL VALVE REMOV ADDL EACH 31651 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321607 PHYSICIAN FEE - SURGERY PF-BRONCHIAL VALVE REMOV INIT EACH 31649 $171.00 960 $119.70 $85.50 $136.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321508 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY BRONCH STENTS EACH 31636 $563.00 960 $394.10 $281.50 $450.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321565 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY CLEAR AIRWAYS EACH 31645 $382.00 960 $267.40 $191.00 $305.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321458 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY DILATE W/STENT EACH 31631 $592.00 960 $414.40 $296.00 $473.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321441 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY DILATE/FX REPR EACH 31630 $520.00 960 $364.00 $260.00 $416.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321573 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY RECLEAR AIRWAY EACH 31646 $368.00 960 $257.60 $184.00 $294.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321524 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY REVISE STENT EACH 31638 $638.00 960 $446.60 $319.00 $510.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321516 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY STENT ADD-ON EACH 31637 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321540 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY TREAT BLOCKAGE EACH 31641 $660.00 960 $462.00 $330.00 $528.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321391 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY W/BIOPSY(S) EACH 31625 $404.00 960 $282.80 $202.00 $323.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321490 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY W/FB REMOVAL EACH 31635 $458.00 960 $320.60 $229.00 $366.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321409 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY W/MARKERS EACH 31626 $517.00 960 $361.90 $258.50 $413.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321532 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY W/TUMOR EXCISE EACH 31640 $641.00 960 $448.70 $320.50 $512.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321466 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY/LUNG BX ADDL EACH 31632 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321425 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY/LUNG BX EACH EACH 31628 $452.00 960 $316.40 $226.00 $361.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321474 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY/NEEDLE BX ADDL EACH 31633 $163.00 960 $114.10 $81.50 $130.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321433 PHYSICIAN FEE - SURGERY PF-BRONCHOSCOPY/NEEDLE BX EACH EACH 31629 $483.00 960 $338.10 $241.50 $386.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344781 PHYSICIAN FEE - SURGERY PF-BSO OMENTECTOMY W/TAH EACH 58956 "$3,722.00 " 960 "$2,605.40 " "$1,861.00 " "$2,977.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345846 PHYSICIAN FEE - SURGERY PF-BURR HOLE FOR PUNCTURE EACH 61120 "$2,242.00 " 960 "$1,569.40 " "$1,121.00 " "$1,793.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313133 PHYSICIAN FEE - SURGERY PF-BUTTOCK FASCIOTOMY EACH 27027 "$2,447.00 " 960 "$1,712.90 " "$1,223.50 " "$1,957.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313281 PHYSICIAN FEE - SURGERY PF-BUTTOCK FASCIOTOMY W/DBRDMT EACH 27057 "$2,778.00 " 960 "$1,944.60 " "$1,389.00 " "$2,222.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343833 PHYSICIAN FEE - SURGERY PF-BX DONE W/COLPOSCOPY ADD-ON EACH 58110 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342777 PHYSICIAN FEE - SURGERY PF-BX LESN VULVA/PERI EACH ADD EACH 56606 $80.00 960 $56.00 $40.00 $64.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343627 PHYSICIAN FEE - SURGERY PF-BX OF CERVIX W/SCOPE LEEP EACH 57460 $435.00 960 $304.50 $217.50 $348.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343593 PHYSICIAN FEE - SURGERY PF-BX/CURETT OF CERVIX W/SCOPE EACH 57454 $365.00 960 $255.50 $182.50 $292.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326945 PHYSICIAN FEE - SURGERY PF-BYPASS GRAFT NOT VEIN EACH 35623 "$3,717.00 " 960 "$2,601.90 " "$1,858.50 " "$2,973.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327182 PHYSICIAN FEE - SURGERY PF-BYPASS GRAFT PATENCY/PATCH EACH 35685 $561.00 960 $392.70 $280.50 $448.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327190 PHYSICIAN FEE - SURGERY PF-BYPASS GRFT/AV FIST PATENCY EACH 35686 $455.00 960 $318.50 $227.50 $364.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324189 PHYSICIAN FEE - SURGERY PF-CABG ARTERIAL FOUR OR MORE EACH 33536 "$7,358.00 " 960 "$5,150.60 " "$3,679.00 " "$5,886.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324155 PHYSICIAN FEE - SURGERY PF-CABG ARTERIAL SINGLE EACH 33533 "$5,229.00 " 960 "$3,660.30 " "$2,614.50 " "$4,183.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324171 PHYSICIAN FEE - SURGERY PF-CABG ARTERIAL THREE EACH 33535 "$6,827.00 " 960 "$4,778.90 " "$3,413.50 " "$5,461.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324163 PHYSICIAN FEE - SURGERY PF-CABG ARTERIAL TWO EACH 33534 "$6,145.00 " 960 "$4,301.50 " "$3,072.50 " "$4,916.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324122 PHYSICIAN FEE - SURGERY PF-CABG ARTERY-VEIN FIVE EACH 33522 "$2,049.00 " 960 "$1,434.30 " "$1,024.50 " "$1,639.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324114 PHYSICIAN FEE - SURGERY PF-CABG ARTERY-VEIN FOUR EACH 33521 "$1,331.00 " 960 $931.70 $665.50 "$1,064.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324080 PHYSICIAN FEE - SURGERY PF-CABG ARTERY-VEIN SINGLE EACH 33517 $526.00 960 $368.20 $263.00 $420.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324106 PHYSICIAN FEE - SURGERY PF-CABG ARTERY-VEIN THREE EACH 33519 "$1,521.00 " 960 "$1,064.70 " $760.50 "$1,216.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324098 PHYSICIAN FEE - SURGERY PF-CABG ARTERY-VEIN TWO EACH 33518 "$1,149.00 " 960 $804.30 $574.50 $919.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324130 PHYSICIAN FEE - SURGERY PF-CABG ART-VEIN SIX OR MORE EACH 33523 "$2,297.00 " 960 "$1,607.90 " "$1,148.50 " "$1,837.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324064 PHYSICIAN FEE - SURGERY PF-CABG VEIN FIVE EACH 33514 "$7,242.00 " 960 "$5,069.40 " "$3,621.00 " "$5,793.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324056 PHYSICIAN FEE - SURGERY PF-CABG VEIN FOUR EACH 33513 "$6,910.00 " 960 "$4,837.00 " "$3,455.00 " "$5,528.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324023 PHYSICIAN FEE - SURGERY PF-CABG VEIN SINGLE EACH 33510 "$5,397.00 " 960 "$3,777.90 " "$2,698.50 " "$4,317.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324072 PHYSICIAN FEE - SURGERY PF-CABG VEIN SIX OR MORE EACH 33516 "$7,495.00 " 960 "$5,246.50 " "$3,747.50 " "$5,996.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324049 PHYSICIAN FEE - SURGERY PF-CABG VEIN THREE EACH 33512 "$6,762.00 " 960 "$4,733.40 " "$3,381.00 " "$5,409.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324031 PHYSICIAN FEE - SURGERY PF-CABG VEIN TWO EACH 33511 "$5,929.00 " 960 "$4,150.30 " "$2,964.50 " "$4,743.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359235 PHYSICIAN FEE - SURGERY PF-CANALITH REPOSITIONING PROC EACH 95992 $91.00 960 $63.70 $45.50 $72.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328644 PHYSICIAN FEE - SURGERY PF-CANNULA DECLOTTING EACH 36861 $392.00 960 $274.40 $196.00 $313.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353014 PHYSICIAN FEE - SURGERY PF-CANTHOPLASTY EACH 67950 "$1,186.00 " 960 $830.20 $593.00 $948.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325095 PHYSICIAN FEE - SURGERY PF-CAR-CAR BP GRFT/ENDOVAS TAA EACH 33891 "$2,731.00 " 960 "$1,911.70 " "$1,365.50 " "$2,184.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360746 PHYSICIAN FEE - SURGERY PF-CARDIAC SURGERY PROC NOS EACH 33999 "$1,381.00 " 960 $966.70 $690.50 "$1,104.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358575 PHYSICIAN FEE - SURGERY PF-CARDIAC SURGERY PROC NOS EACH 34707 "$3,253.00 " 960 "$2,277.10 " "$1,626.50 " "$2,602.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345200 PHYSICIAN FEE - SURGERY PF-CARE AFTER DELIVERY EACH 59430 $521.00 960 $364.70 $260.50 $416.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345325 PHYSICIAN FEE - SURGERY PF-CARE OF MISCARRIAGE EACH 59820 "$1,100.00 " 960 $770.00 $550.00 $880.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350051 PHYSICIAN FEE - SURGERY PF-CARPAL TUNNEL SURGERY EACH 64721 "$1,196.00 " 960 $837.20 $598.00 $956.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351901 PHYSICIAN FEE - SURGERY PF-CATARACT SURG W/IOL 1 STAGE EACH 66983 "$2,034.00 " 960 "$1,423.80 " "$1,017.00 " "$1,627.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351919 PHYSICIAN FEE - SURGERY PF-CATARACT SURG W/IOL 1 STAGE EACH 66984 "$1,387.00 " 960 $970.90 $693.50 "$1,109.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351893 PHYSICIAN FEE - SURGERY PF-CATARACT SURGERY COMPLEX EACH 66982 "$1,903.00 " 960 "$1,332.10 " $951.50 "$1,522.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339757 PHYSICIAN FEE - SURGERY PF-CATH BLADDER NON-INDWELLING EACH 51701 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339773 PHYSICIAN FEE - SURGERY PF-CATH BLADDER TEMP INDW CPLX EACH 51703 $202.00 960 $141.40 $101.00 $161.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344120 PHYSICIAN FEE - SURGERY PF-CATHETER FOR HYSTEROGRAPHY EACH 58340 $156.00 960 $109.20 $78.00 $124.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343668 PHYSICIAN FEE - SURGERY PF-CAUTERIZATION OF CERVIX EACH 57510 $310.00 960 $217.00 $155.00 $248.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324692 PHYSICIAN FEE - SURGERY PF-CAVOPULMONARY SHUNTING EACH 33768 "$1,171.00 " 960 $819.70 $585.50 $936.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307424 PHYSICIAN FEE - SURGERY PF-CERV ARTIFIC DISKECTOMY EACH 22856 "$4,695.00 " 960 "$3,286.50 " "$2,347.50 " "$3,756.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348246 PHYSICIAN FEE - SURGERY PF-CERVICAL LAMINOPLASTY EACH 63050 "$4,197.00 " 960 "$2,937.90 " "$2,098.50 " "$3,357.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345218 PHYSICIAN FEE - SURGERY PF-CESAREAN DELIVERY EACH 59510 "$7,761.00 " 960 "$5,432.70 " "$3,880.50 " "$6,208.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345234 PHYSICIAN FEE - SURGERY PF-CESAREAN DELIVERY EACH 59515 "$3,913.00 " 960 "$2,739.10 " "$1,956.50 " "$3,130.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345226 PHYSICIAN FEE - SURGERY PF-CESAREAN DELIVERY ONLY EACH 59514 "$2,649.00 " 960 "$1,854.30 " "$1,324.50 " "$2,119.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328883 PHYSICIAN FEE - SURGERY PF-CESSJ THERAPY CATH REMOVAL EACH 37214 $331.00 960 $231.70 $165.50 $264.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338536 PHYSICIAN FEE - SURGERY PF-CHANGE EXT/INT URETER STENT EACH 50387 $216.00 960 $151.20 $108.00 $172.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333503 PHYSICIAN FEE - SURGERY PF-CHANGE GASTRIC PORT OPEN EACH 43888 "$1,307.00 " 960 $914.90 $653.50 "$1,045.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339799 PHYSICIAN FEE - SURGERY PF-CHANGE OF BLADDER TUBE EACH 51710 $213.00 960 $149.10 $106.50 $170.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339021 PHYSICIAN FEE - SURGERY PF-CHANGE OF URETER TUBE/STENT EACH 50688 $203.00 960 $142.10 $101.50 $162.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338510 PHYSICIAN FEE - SURGERY PF-CHANGE STENT VIA TRANSURETH EACH 50385 $563.00 960 $394.10 $281.50 $450.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338494 PHYSICIAN FEE - SURGERY PF-CHANGE URETER STENT PERCUT EACH 50382 $652.00 960 $456.40 $326.00 $521.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356686 PHYSICIAN FEE - SURGERY PF-CHEM/DEST NRV MUSCLE FAC LT EACH 64612 $325.00 960 $227.50 $162.50 $260.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356678 PHYSICIAN FEE - SURGERY PF-CHEM/DEST NRV MUSCLE FAC RT EACH 64612 $325.00 960 $227.50 $162.50 $260.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302508 PHYSICIAN FEE - SURGERY PF-CHEMICAL PEEL FACE DERMAL EACH 15789 "$1,076.00 " 960 $753.20 $538.00 $860.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302490 PHYSICIAN FEE - SURGERY PF-CHEMICAL PEEL FACE EPIDERM EACH 15788 $565.00 960 $395.50 $282.50 $452.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302524 PHYSICIAN FEE - SURGERY PF-CHEMICAL PEEL NONFACIAL EACH 15793 $939.00 960 $657.30 $469.50 $751.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356728 PHYSICIAN FEE - SURGERY PF-CHEMODEN LARYNX W/EMG BI EACH 64617 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356702 PHYSICIAN FEE - SURGERY PF-CHEMODEN LARYNX W/EMG RT EACH 64617 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356744 PHYSICIAN FEE - SURGERY PF-CHEMODEN NECK MUSCLES LT EACH 64616 $318.00 960 $222.60 $159.00 $254.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356736 PHYSICIAN FEE - SURGERY PF-CHEMODEN NECK MUSCLES RT EACH 64616 $318.00 960 $222.60 $159.00 $254.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349897 PHYSICIAN FEE - SURGERY PF-CHEMODENERV 1 EXTREM 1-4 EA EACH 64643 $193.00 960 $135.10 $96.50 $154.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349913 PHYSICIAN FEE - SURGERY PF-CHEMODENERV 1 EXTREM 5/> EA EACH 64645 $229.00 960 $160.30 $114.50 $183.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349905 PHYSICIAN FEE - SURGERY PF-CHEMODENERV 1 EXTREM 5/>MUS EACH 64644 $322.00 960 $225.40 $161.00 $257.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349889 PHYSICIAN FEE - SURGERY PF-CHEMODENERV 1 EXTREMITY 1-4 EACH 64642 $301.00 960 $210.70 $150.50 $240.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349921 PHYSICIAN FEE - SURGERY PF-CHEMODENERV ECCRINE GLANDS EACH 64650 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349939 PHYSICIAN FEE - SURGERY PF-CHEMODENERV ECCRINE GLANDS EACH 64653 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349780 PHYSICIAN FEE - SURGERY PF-CHEMODENERV MUSC MIGRAINE EACH 64615 $359.00 960 $251.30 $179.50 $287.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349764 PHYSICIAN FEE - SURGERY PF-CHEMODENERV SALIV GLANDS EACH 64611 $319.00 960 $223.30 $159.50 $255.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355100 PHYSICIAN FEE - SURGERY PF-CHEMODENERV TRUNK MUSC 1-5 EACH 64646 $330.00 960 $231.00 $165.00 $264.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355118 PHYSICIAN FEE - SURGERY PF-CHEMODENERV TRUNK MUSC 6/> EACH 64647 $382.00 960 $267.40 $191.00 $305.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335656 PHYSICIAN FEE - SURGERY PF-CHEMODENERVATION ANAL MUSC EACH 46505 $673.00 960 $471.10 $336.50 $538.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344880 PHYSICIAN FEE - SURGERY PF-CHORION BIOPSY EACH 59015 $384.00 960 $268.80 $192.00 $307.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351737 PHYSICIAN FEE - SURGERY PF-CILIARY ENDOSCOPIC ABLATION EACH 66711 "$1,293.00 " 960 $905.10 $646.50 "$1,034.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351729 PHYSICIAN FEE - SURGERY PF-CILIARY TRANSSLERAL THERAPY EACH 66710 "$1,001.00 " 960 $700.70 $500.50 $800.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341464 PHYSICIAN FEE - SURGERY PF-CIRCUMCISION NEONATE EACH 54160 $388.00 960 $271.60 $194.00 $310.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341456 PHYSICIAN FEE - SURGERY PF-CIRCUMCISION W/REG BLOCK EACH 54150 $256.00 960 $179.20 $128.00 $204.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340037 PHYSICIAN FEE - SURGERY PF-CL BLADDER-UTERUS FISTULA EACH 51920 "$2,028.00 " 960 "$1,419.60 " "$1,014.00 " "$1,622.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324445 PHYSICIAN FEE - SURGERY PF-CL MULT VSD W/REM PUL BAND EACH 33677 "$5,903.00 " 960 "$4,132.10 " "$2,951.50 " "$4,722.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348253 PHYSICIAN FEE - SURGERY PF-C-LAMINOPLASTY W/GRFT/PLATE EACH 63051 "$4,871.00 " 960 "$3,409.70 " "$2,435.50 " "$3,896.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347032 PHYSICIAN FEE - SURGERY PF-CLAMP NECK ARTERY EACH 61703 "$4,094.00 " 960 "$2,865.80 " "$2,047.00 " "$3,275.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353675 PHYSICIAN FEE - SURGERY PF-CLEAN OUT MASTOID CAVITY EACH 69222 $362.00 960 $253.40 $181.00 $289.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353634 PHYSICIAN FEE - SURGERY PF-CLEAR OUTER EAR CANAL EACH 69200 $127.00 960 $88.90 $63.50 $101.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353642 PHYSICIAN FEE - SURGERY PF-CLEAR OUTER EAR CANAL EACH 69205 $254.00 960 $177.80 $127.00 $203.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321656 PHYSICIAN FEE - SURGERY PF-CLEARANCE OF AIRWAYS EACH 31720 $125.00 960 $87.50 $62.50 $100.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321664 PHYSICIAN FEE - SURGERY PF-CLEARANCE OF AIRWAYS EACH 31725 $204.00 960 $142.80 $102.00 $163.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353345 PHYSICIAN FEE - SURGERY PF-CLEARANCE OF TEAR DUCT EACH 68530 $651.00 960 $455.70 $325.50 $520.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322647 PHYSICIAN FEE - SURGERY PF-CLOSE BRONCHIAL FISTULA EACH 32815 "$7,855.00 " 960 "$5,498.50 " "$3,927.50 " "$6,284.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322639 PHYSICIAN FEE - SURGERY PF-CLOSE CHEST AFTER DRAINAGE EACH 32810 "$2,527.00 " 960 "$1,768.90 " "$1,263.50 " "$2,021.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338668 PHYSICIAN FEE - SURGERY PF-CLOSE KIDNEY-SKIN FISTULA EACH 50520 "$3,291.00 " 960 "$2,303.70 " "$1,645.50 " "$2,632.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354152 PHYSICIAN FEE - SURGERY PF-CLOSE MASTOID FISTULA EACH 69700 "$1,775.00 " 960 "$1,242.50 " $887.50 "$1,420.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324429 PHYSICIAN FEE - SURGERY PF-CLOSE MULT VSD EACH 33675 "$5,535.00 " 960 "$3,874.50 " "$2,767.50 " "$4,428.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324437 PHYSICIAN FEE - SURGERY PF-CLOSE MULT VSD W/RESECTION EACH 33676 "$5,684.00 " 960 "$3,978.80 " "$2,842.00 " "$4,547.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353428 PHYSICIAN FEE - SURGERY PF-CLOSE TEAR DUCT OPENING EACH 68760 $374.00 960 $261.80 $187.00 $299.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353436 PHYSICIAN FEE - SURGERY PF-CLOSE TEAR DUCT OPENING EACH 68761 $297.00 960 $207.90 $148.50 $237.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353444 PHYSICIAN FEE - SURGERY PF-CLOSE TEAR SYSTEM FISTULA EACH 68770 "$1,600.00 " 960 "$1,120.00 " $800.00 "$1,280.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339294 PHYSICIAN FEE - SURGERY PF-CLOSE URETER/BOWEL FISTULA EACH 50930 "$2,915.00 " 960 "$2,040.50 " "$1,457.50 " "$2,332.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352776 PHYSICIAN FEE - SURGERY PF-CLOSURE OF EYELID BY SUTURE EACH 67875 $246.00 960 $172.20 $123.00 $196.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331358 PHYSICIAN FEE - SURGERY PF-CLOSURE OF SALIVARY FISTULA EACH 42600 $959.00 960 $671.30 $479.50 $767.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301344 PHYSICIAN FEE - SURGERY PF-CLOSURE OF SPLIT WOUND EACH 12020 $505.00 960 $353.50 $252.50 $404.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343098 PHYSICIAN FEE - SURGERY PF-CLOSURE OF VAGINA EACH 57120 "$1,443.00 " 960 "$1,010.10 " $721.50 "$1,154.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324239 PHYSICIAN FEE - SURGERY PF-CLOSURE OF VALVE EACH 33600 "$4,828.00 " 960 "$3,379.60 " "$2,414.00 " "$3,862.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324247 PHYSICIAN FEE - SURGERY PF-CLOSURE OF VALVE EACH 33602 "$4,686.00 " 960 "$3,280.20 " "$2,343.00 " "$3,748.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321805 PHYSICIAN FEE - SURGERY PF-CLOSURE OF WINDPIPE LESION EACH 31820 $896.00 960 $627.20 $448.00 $716.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339286 PHYSICIAN FEE - SURGERY PF-CLOSURE URETER/SKIN FISTULA EACH 50920 "$2,339.00 " 960 "$1,637.30 " "$1,169.50 " "$1,871.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358690 PHYSICIAN FEE - SURGERY PF-CLSD TX PELVIC RING FX EACH 36482 $495.00 960 $346.50 $247.50 $396.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358781 PHYSICIAN FEE - SURGERY PF-CLSD TX PELVIC RING FX EACH 64912 "$2,431.00 " 960 "$1,701.70 " "$1,215.50 " "$1,944.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359391 PHYSICIAN FEE - SURGERY PF-CLSD TX PELVIC RING FX EACH 27197 $362.00 960 $253.40 $181.00 $289.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359409 PHYSICIAN FEE - SURGERY PF-CLSD TX PELVIC RING FX EACH 27198 $862.00 960 $603.40 $431.00 $689.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316367 PHYSICIAN FEE - SURGERY PF-CLTX MED ANKLE FX W/MNPJ EACH 27762 "$1,229.00 " 960 $860.30 $614.50 $983.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316383 PHYSICIAN FEE - SURGERY PF-CLTX POST ANKLE FX EACH 27767 $795.00 960 $556.50 $397.50 $636.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316391 PHYSICIAN FEE - SURGERY PF-CLTX POST ANKLE FX W/MNPJ EACH 27768 "$1,244.00 " 960 $870.80 $622.00 $995.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314131 PHYSICIAN FEE - SURGERY PF-CLTX THIGH FX EACH 27267 "$1,225.00 " 960 $857.50 $612.50 $980.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314149 PHYSICIAN FEE - SURGERY PF-CLTX THIGH FX W/MNPJ EACH 27268 "$1,507.00 " 960 "$1,054.90 " $753.50 "$1,205.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304363 PHYSICIAN FEE - SURGERY PF-CMP EXT FIXATE STRUT CHANGE EACH 20697 "$4,450.00 " 960 "$3,115.00 " "$2,225.00 " "$3,560.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304355 PHYSICIAN FEE - SURGERY PF-CMP MULTIPLANE EXT FIXATION EACH 20696 "$3,164.00 " 960 "$2,214.80 " "$1,582.00 " "$2,531.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301666 PHYSICIAN FEE - SURGERY PF-CMPL RPR E/N/E/L ADDL 5CM/< EACH 13153 $367.00 960 $256.90 $183.50 $293.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320245 PHYSICIAN FEE - SURGERY PF-CNTR NOSEBLEED POST INITIAL EACH 30905 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333826 PHYSICIAN FEE - SURGERY PF-COLECTMY W/NEO-RECTUM POUCH EACH 44158 "$6,334.00 " 960 "$4,433.80 " "$3,167.00 " "$5,067.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333818 PHYSICIAN FEE - SURGERY PF-COLECTOMY W/ILEOANAL ANAST EACH 44157 "$6,177.00 " 960 "$4,323.90 " "$3,088.50 " "$4,941.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328362 PHYSICIAN FEE - SURGERY PF-COLLECT BLOOD FROM PICC EACH 36592 $77.00 960 $53.90 $38.50 $61.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355241 PHYSICIAN FEE - SURGERY PF-COLON CA SCRN NOT HI RS EACH G0121 $246.00 960 $172.20 $123.00 $196.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334287 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY EACH 44388 $210.00 960 $147.00 $105.00 $168.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334329 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY & POLYPECTOMY EACH 44392 $540.00 960 $378.00 $270.00 $432.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335086 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY AND BIOPSY EACH 45380 $527.00 960 $368.90 $263.50 $421.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334311 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY FOR BLEEDING EACH 44391 $606.00 960 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335094 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY SUBMUCOUS INJ EACH 45381 $527.00 960 $368.90 $263.50 $421.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357619 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/ABLATION EACH 45388 $713.00 960 $499.10 $356.50 $570.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359953 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/BAND LIGATION EACH 45398 $628.00 960 $439.60 $314.00 $502.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359888 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/DECOMPRESSION EACH 44408 $605.00 960 $423.50 $302.50 $484.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359946 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/DECOMPRESSION EACH 45393 $665.00 960 $465.50 $332.50 $532.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359854 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/DILATION EACH 44405 $481.00 960 $336.70 $240.50 $384.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335144 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/ENDOSCOPE US EACH 45391 $674.00 960 $471.80 $337.00 $539.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335078 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/FB REMOVAL EACH 45379 $626.00 960 $438.20 $313.00 $500.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359847 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/INJECTION EACH 44404 $454.00 960 $317.80 $227.00 $363.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359870 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/NDL ASPIR/BX EACH 44407 $720.00 960 $504.00 $360.00 $576.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358633 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/RESECTION EACH 34713 $347.00 960 $242.90 $173.50 $277.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359839 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/RESECTION EACH 44403 $797.00 960 $557.90 $398.50 $637.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359938 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/RESECTION EACH 45390 $871.00 960 $609.70 $435.50 $696.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334337 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/SNARE EACH 44394 $596.00 960 $417.20 $298.00 $476.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359920 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/STENT PLCMT EACH 45389 $759.00 960 $531.30 $379.50 $607.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359862 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY W/ULTRASOUND EACH 44406 $600.00 960 $420.00 $300.00 $480.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359813 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY WITH ABLATION EACH 44401 $634.00 960 $443.80 $317.00 $507.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334295 PHYSICIAN FEE - SURGERY PF-COLONOSCOPY WITH BIOPSY EACH 44389 $454.00 960 $317.80 $227.00 $363.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335136 PHYSICIAN FEE - SURGERY PF-COLONOSCPY DILATE STRICTURE EACH 45386 $558.00 960 $390.60 $279.00 $446.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334303 PHYSICIAN FEE - SURGERY PF-COLONOSCPY FOR FOREIGN BODY EACH 44390 $551.00 960 $385.70 $275.50 $440.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335151 PHYSICIAN FEE - SURGERY PF-COLONOSCPY W/ENDOSCOPIC FNB EACH 45392 $797.00 960 $557.90 $398.50 $637.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335102 PHYSICIAN FEE - SURGERY PF-COLONOSCPY/CONTROL BLEEDING EACH 45382 $677.00 960 $473.90 $338.50 $541.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357494 PHYSICIAN FEE - SURGERY PF-COLORECTAL SCRN HI RISK IND EACH G0105 $244.00 960 $170.80 $122.00 $195.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334055 PHYSICIAN FEE - SURGERY PF-COLOSTOMY EACH 44320 "$3,350.00 " 960 "$2,345.00 " "$1,675.00 " "$2,680.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334063 PHYSICIAN FEE - SURGERY PF-COLOSTOMY WITH BIOPSIES EACH 44322 "$2,793.00 " 960 "$1,955.10 " "$1,396.50 " "$2,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343304 PHYSICIAN FEE - SURGERY PF-COLPOPEXY EXTRAPERITONEAL EACH 57282 "$1,886.00 " 960 "$1,320.20 " $943.00 "$1,508.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343312 PHYSICIAN FEE - SURGERY PF-COLPOPEXY INTRAPERITONEAL EACH 57283 "$1,904.00 " 960 "$1,332.80 " $952.00 "$1,523.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342793 PHYSICIAN FEE - SURGERY PF-COMPLETE REMOVAL OF VULVA EACH 56625 "$1,816.00 " 960 "$1,271.20 " $908.00 "$1,452.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322126 PHYSICIAN FEE - SURGERY PF-COMPLETION PNEUMONECTOMY EACH 32488 "$6,717.00 " 960 "$4,701.90 " "$3,358.50 " "$5,373.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300122 PHYSICIAN FEE - SURGERY PF-COMPLEX DRAINAGE WOUND EACH 10180 $490.00 960 $343.00 $245.00 $392.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327158 PHYSICIAN FEE - SURGERY PF-COMPOSITE BYPASS GRAFT EACH 35681 $226.00 960 $158.20 $113.00 $180.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327166 PHYSICIAN FEE - SURGERY PF-COMPOSITE BYPASS GRAFT EACH 35682 $998.00 960 $698.60 $499.00 $798.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327174 PHYSICIAN FEE - SURGERY PF-COMPOSITE BYPASS GRAFT EACH 35683 "$1,159.00 " 960 $811.30 $579.50 $927.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302383 PHYSICIAN FEE - SURGERY PF-COMPOSITE SKIN GRAFT EACH 15760 "$1,855.00 " 960 "$1,298.50 " $927.50 "$1,484.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343700 PHYSICIAN FEE - SURGERY PF-CONE CERVIX LOOP ELECTR EXC EACH 57522 $694.00 960 $485.80 $347.00 $555.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353162 PHYSICIAN FEE - SURGERY PF-CONJUNCTIVOPLASTY W/GRAFT EACH 68320 "$1,381.00 " 960 $966.70 $690.50 "$1,104.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353188 PHYSICIAN FEE - SURGERY PF-CONJUNCTIVOPLSTY CUL-DE-SAC EACH 68326 "$1,649.00 " 960 "$1,154.30 " $824.50 "$1,319.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340078 PHYSICIAN FEE - SURGERY PF-CONSTRUCT BLADDER OPENING EACH 51980 "$1,896.00 " 960 "$1,327.20 " $948.00 "$1,516.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339211 PHYSICIAN FEE - SURGERY PF-CONSTRUCT BOWEL BLADDER EACH 50820 "$3,489.00 " 960 "$2,442.30 " "$1,744.50 " "$2,791.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339229 PHYSICIAN FEE - SURGERY PF-CONSTRUCT BOWEL BLADDER EACH 50825 "$4,356.00 " 960 "$3,049.20 " "$2,178.00 " "$3,484.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312390 PHYSICIAN FEE - SURGERY PF-CONSTRUCT THUMB REPLACEMENT EACH 26550 "$4,507.00 " 960 "$3,154.90 " "$2,253.50 " "$3,605.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343387 PHYSICIAN FEE - SURGERY PF-CONSTRUCT VAGINA WITH GRAFT EACH 57292 "$2,265.00 " 960 "$1,585.50 " "$1,132.50 " "$1,812.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335839 PHYSICIAN FEE - SURGERY PF-CONSTRUCTION OF ABSENT ANUS EACH 46730 "$5,610.00 " 960 "$3,927.00 " "$2,805.00 " "$4,488.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335847 PHYSICIAN FEE - SURGERY PF-CONSTRUCTION OF ABSENT ANUS EACH 46735 "$6,468.00 " 960 "$4,527.60 " "$3,234.00 " "$5,174.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335854 PHYSICIAN FEE - SURGERY PF-CONSTRUCTION OF ABSENT ANUS EACH 46740 "$6,127.00 " 960 "$4,288.90 " "$3,063.50 " "$4,901.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343379 PHYSICIAN FEE - SURGERY PF-CONSTRUCTION OF VAGINA EACH 57291 "$1,502.00 " 960 "$1,051.40 " $751.00 "$1,201.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305345 PHYSICIAN FEE - SURGERY PF-CONTOUR CRANIAL BONE LESION EACH 21181 "$2,008.00 " 960 "$1,405.60 " "$1,004.00 " "$1,606.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304793 PHYSICIAN FEE - SURGERY PF-CONTOUR OF FACE BONE LESION EACH 21029 "$1,681.00 " 960 "$1,176.70 " $840.50 "$1,344.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331721 PHYSICIAN FEE - SURGERY PF-CONTROL NOSE/THROAT BLEED EACH 42970 "$1,106.00 " 960 $774.20 $553.00 $884.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331739 PHYSICIAN FEE - SURGERY PF-CONTROL NOSE/THROAT BLEED EACH 42971 "$1,221.00 " 960 $854.70 $610.50 $976.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331747 PHYSICIAN FEE - SURGERY PF-CONTROL NOSE/THROAT BLEED EACH 42972 "$1,366.00 " 960 $956.20 $683.00 "$1,092.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331697 PHYSICIAN FEE - SURGERY PF-CONTROL THROAT BLEEDING EACH 42960 $435.00 960 $304.50 $217.50 $348.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331705 PHYSICIAN FEE - SURGERY PF-CONTROL THROAT BLEEDING EACH 42961 "$1,128.00 " 960 $789.60 $564.00 $902.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331713 PHYSICIAN FEE - SURGERY PF-CONTROL THROAT BLEEDING EACH 42962 "$1,391.00 " 960 $973.70 $695.50 "$1,112.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343635 PHYSICIAN FEE - SURGERY PF-CONZ OF CERVIX W/SCOPE LEEP EACH 57461 $500.00 960 $350.00 $250.00 $400.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351224 PHYSICIAN FEE - SURGERY PF-CORNEAL TRNSPL ENDOTHELIAL EACH 65756 "$3,018.00 " 960 "$2,112.60 " "$1,509.00 " "$2,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324148 PHYSICIAN FEE - SURGERY PF-CORONARY ARTERY BYPASS/REOP EACH 33530 "$1,466.00 " 960 "$1,026.20 " $733.00 "$1,172.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323959 PHYSICIAN FEE - SURGERY PF-CORONARY ARTERY CORRECTION EACH 33502 "$3,586.00 " 960 "$2,510.20 " "$1,793.00 " "$2,868.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323967 PHYSICIAN FEE - SURGERY PF-CORONARY ARTERY GRAFT EACH 33503 "$3,723.00 " 960 "$2,606.10 " "$1,861.50 " "$2,978.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323975 PHYSICIAN FEE - SURGERY PF-CORONARY ARTERY GRAFT EACH 33504 "$4,116.00 " 960 "$2,881.20 " "$2,058.00 " "$3,292.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317720 PHYSICIAN FEE - SURGERY PF-CORRECT BUNION DBL OSTEOTMY EACH 28299 "$1,585.00 " 960 "$1,109.50 " $792.50 "$1,268.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317704 PHYSICIAN FEE - SURGERY PF-CORRECT BUNION LAPIDUS-TYPE EACH 28297 "$1,604.00 " 960 "$1,122.80 " $802.00 "$1,283.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317712 PHYSICIAN FEE - SURGERY PF-CORRECT BUNION PHALNX OSTEO EACH 28298 "$1,355.00 " 960 $948.50 $677.50 "$1,084.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317696 PHYSICIAN FEE - SURGERY PF-CORRECT BUNION-MITCH/CHEVRN EACH 28296 "$1,353.00 " 960 $947.10 $676.50 "$1,082.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312499 PHYSICIAN FEE - SURGERY PF-CORRECT FINGER DEFORMITY EACH 26567 "$1,931.00 " 960 "$1,351.70 " $965.50 "$1,544.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303787 PHYSICIAN FEE - SURGERY PF-CORRECT INVERTED NIPPLE(S) EACH 19355 "$1,674.00 " 960 "$1,171.80 " $837.00 "$1,339.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333586 PHYSICIAN FEE - SURGERY PF-CORRECT MALROTATION BOWEL EACH 44055 "$4,217.00 " 960 "$2,951.90 " "$2,108.50 " "$3,373.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312481 PHYSICIAN FEE - SURGERY PF-CORRECT METACARPAL FLAW EACH 26565 "$1,908.00 " 960 "$1,335.60 " $954.00 "$1,526.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335235 PHYSICIAN FEE - SURGERY PF-CORRECT RECTAL PROLAPSE EACH 45540 "$2,354.00 " 960 "$1,647.80 " "$1,177.00 " "$1,883.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335243 PHYSICIAN FEE - SURGERY PF-CORRECT RECTAL PROLAPSE EACH 45541 "$2,566.00 " 960 "$1,796.20 " "$1,283.00 " "$2,052.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340052 PHYSICIAN FEE - SURGERY PF-CORRECTION BLADDER DEFECT EACH 51940 "$4,340.00 " 960 "$3,038.00 " "$2,170.00 " "$3,472.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352891 PHYSICIAN FEE - SURGERY PF-CORRECTION EYELID W/IMPLANT EACH 67912 "$1,259.00 " 960 $881.30 $629.50 "$1,007.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358724 PHYSICIAN FEE - SURGERY PF-CORRECTION HALLUX VALGUS EACH 38573 "$3,210.00 " 960 "$2,247.00 " "$1,605.00 " "$2,568.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358856 PHYSICIAN FEE - SURGERY PF-CORRECTION HALLUX VALGUS EACH 28295 "$1,616.00 " 960 "$1,131.20 " $808.00 "$1,292.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351257 PHYSICIAN FEE - SURGERY PF-CORRECTION OF ASTIGMATISM EACH 65772 "$1,037.00 " 960 $725.90 $518.50 $829.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351265 PHYSICIAN FEE - SURGERY PF-CORRECTION OF ASTIGMATISM EACH 65775 "$1,467.00 " 960 "$1,026.90 " $733.50 "$1,173.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359425 PHYSICIAN FEE - SURGERY PF-CORRJ HALUX RIGDUS W/IMPLT EACH 28291 "$1,266.00 " 960 $886.20 $633.00 "$1,012.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351273 PHYSICIAN FEE - SURGERY PF-COVER EYE W/MEMBRANE EACH 65778 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351281 PHYSICIAN FEE - SURGERY PF-COVER EYE W/MEMBRANE STENT EACH 65779 $302.00 960 $211.40 $151.00 $241.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304694 PHYSICIAN FEE - SURGERY PF-CPTR-ASST DIR MS PX EACH 20985 $399.00 960 $279.30 $199.50 $319.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357817 PHYSICIAN FEE - SURGERY PF-CRANIO/MAXILLOFAC SURG NOS EACH 21299 $575.00 960 $402.50 $287.50 $460.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346596 PHYSICIAN FEE - SURGERY PF-CRANIOFACIAL APPROACH SKULL EACH 61580 "$6,833.00 " 960 "$4,783.10 " "$3,416.50 " "$5,466.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346604 PHYSICIAN FEE - SURGERY PF-CRANIOFACIAL APPROACH SKULL EACH 61581 "$7,237.00 " 960 "$5,065.90 " "$3,618.50 " "$5,789.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346612 PHYSICIAN FEE - SURGERY PF-CRANIOFACIAL APPROACH SKULL EACH 61582 "$8,626.00 " 960 "$6,038.20 " "$4,313.00 " "$6,900.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346620 PHYSICIAN FEE - SURGERY PF-CRANIOFACIAL APPROACH SKULL EACH 61583 "$8,577.00 " 960 "$6,003.90 " "$4,288.50 " "$6,861.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353741 PHYSICIAN FEE - SURGERY PF-CREATE EARDRUM OPENING EACH 69433 $354.00 960 $247.80 $177.00 $283.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360381 PHYSICIAN FEE - SURGERY PF-CREATE EARDRUM OPENING EACH 69436 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344625 PHYSICIAN FEE - SURGERY PF-CREATE NEW TUBAL OPENING EACH 58770 "$2,360.00 " 960 "$1,652.00 " "$1,180.00 " "$1,888.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340466 PHYSICIAN FEE - SURGERY PF-CREATE PASSAGE TO KIDNEY EACH 52334 $480.00 960 $336.00 $240.00 $384.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353402 PHYSICIAN FEE - SURGERY PF-CREATE TEAR DUCT DRAIN EACH 68745 "$2,083.00 " 960 "$1,458.10 " "$1,041.50 " "$1,666.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353410 PHYSICIAN FEE - SURGERY PF-CREATE TEAR DUCT DRAIN EACH 68750 "$2,205.00 " 960 "$1,543.50 " "$1,102.50 " "$1,764.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353394 PHYSICIAN FEE - SURGERY PF-CREATE TEAR SAC DRAIN EACH 68720 "$2,076.00 " 960 "$1,453.20 " "$1,038.00 " "$1,660.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359490 PHYSICIAN FEE - SURGERY PF-CRICOTRACHEAL RESECTION EACH 31592 "$4,626.00 " 960 "$3,238.20 " "$2,313.00 " "$3,700.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325574 PHYSICIAN FEE - SURGERY PF-CROSS-OVER VEIN GRAFT EACH 34520 "$2,793.00 " 960 "$1,955.10 " "$1,396.50 " "$2,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342652 PHYSICIAN FEE - SURGERY PF-CRYOABLATE PROSTATE EACH 55873 "$2,030.00 " 960 "$1,421.00 " "$1,015.00 " "$1,624.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338353 PHYSICIAN FEE - SURGERY PF-CRYOABLATE RENAL MASS OPEN EACH 50250 "$3,222.00 " 960 "$2,255.40 " "$1,611.00 " "$2,577.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343676 PHYSICIAN FEE - SURGERY PF-CRYOCAUTERY OF CERVIX EACH 57511 $399.00 960 $279.30 $199.50 $319.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303456 PHYSICIAN FEE - SURGERY PF-CRYOSURG ABLATE FA EACH EACH 19105 $598.00 960 $418.60 $299.00 $478.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335995 PHYSICIAN FEE - SURGERY PF-CRYOSURGERY ANAL LESION(S) EACH 46916 $374.00 960 $261.80 $187.00 $299.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341316 PHYSICIAN FEE - SURGERY PF-CRYOSURGERY PENIS LESION(S) EACH 54056 $293.00 960 $205.10 $146.50 $234.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347677 PHYSICIAN FEE - SURGERY PF-CSF SHUNT REPROGRAM EACH 62252 $103.00 960 $72.10 $51.50 $82.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302003 PHYSICIAN FEE - SURGERY PF-CULT EPIDERM GRAFT F/N/HF/G EACH 15155 "$1,969.00 " 960 "$1,378.30 " $984.50 "$1,575.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301997 PHYSICIAN FEE - SURGERY PF-CULT EPIDERM GRAFT T/A/L +% EACH 15152 $385.00 960 $269.50 $192.50 $308.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301971 PHYSICIAN FEE - SURGERY PF-CULT EPIDERM GRFT T/ARM/LEG EACH 15150 "$1,797.00 " 960 "$1,257.90 " $898.50 "$1,437.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302029 PHYSICIAN FEE - SURGERY PF-CULT EPIDERM GRT F/N/HFG +% EACH 15157 $467.00 960 $326.90 $233.50 $373.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301989 PHYSICIAN FEE - SURGERY PF-CULT EPIDERM GRT T/A/L ADDL EACH 15151 $311.00 960 $217.70 $155.50 $248.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302011 PHYSICIAN FEE - SURGERY PF-CULT EPIDRM GRT F/N/HFG ADD EACH 15156 $429.00 960 $300.30 $214.50 $343.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351141 PHYSICIAN FEE - SURGERY PF-CURETTE/TREAT CORNEA EACH 65435 $178.00 960 $124.60 $89.00 $142.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351158 PHYSICIAN FEE - SURGERY PF-CURETTE/TREAT CORNEA EACH 65436 $946.00 960 $662.20 $473.00 $756.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306798 PHYSICIAN FEE - SURGERY PF-CUT SPINE 3 COL ADDL SEG EACH 22208 "$1,725.00 " 960 "$1,207.50 " $862.50 "$1,380.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306780 PHYSICIAN FEE - SURGERY PF-CUT SPINE 3 COL LUMB EACH 22207 "$6,909.00 " 960 "$4,836.30 " "$3,454.50 " "$5,527.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306772 PHYSICIAN FEE - SURGERY PF-CUT SPINE 3 COL THOR EACH 22206 "$7,116.00 " 960 "$4,981.20 " "$3,558.00 " "$5,692.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358799 PHYSICIAN FEE - SURGERY PF-CYPASS SUPRACHOROIDAL SHUNT EACH 64913 $468.00 960 $327.60 $234.00 $374.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340490 PHYSICIAN FEE - SURGERY PF-CYSTO W/RENAL STRICTURE TX EACH 52343 $905.00 960 $633.50 $452.50 $724.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340482 PHYSICIAN FEE - SURGERY PF-CYSTO W/UP STRICTURE TX EACH 52342 $815.00 960 $570.50 $407.50 $652.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340474 PHYSICIAN FEE - SURGERY PF-CYSTO W/URETER STRICTURE TX EACH 52341 $749.00 960 $524.30 $374.50 $599.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340508 PHYSICIAN FEE - SURGERY PF-CYSTO/URETERO STRICTURE TX EACH 52344 $974.00 960 $681.80 $487.00 $779.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340581 PHYSICIAN FEE - SURGERY PF-CYSTO/URETERO W/ LITHOTRPSY EACH 52356 "$1,095.00 " 960 $766.50 $547.50 $876.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340516 PHYSICIAN FEE - SURGERY PF-CYSTO/URETERO W/UP STRICT EACH 52345 "$1,039.00 " 960 $727.30 $519.50 $831.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339849 PHYSICIAN FEE - SURGERY PF-CYSTOMETROGRAM W/UP EACH 51727 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339856 PHYSICIAN FEE - SURGERY PF-CYSTOMETROGRAM W/VP EACH 51728 $269.00 960 $188.30 $134.50 $215.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339864 PHYSICIAN FEE - SURGERY PF-CYSTOMETROGRAM W/VP&UP EACH 51729 $328.00 960 $229.60 $164.00 $262.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340102 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY EACH 52000 $213.00 960 $149.10 $106.50 $170.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340144 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY & DUCT CATHETER EACH 52010 $436.00 960 $305.20 $218.00 $348.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340243 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY & REVISE URETHRA EACH 52270 $478.00 960 $334.60 $239.00 $382.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340250 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY & REVISE URETHRA EACH 52275 $653.00 960 $457.10 $326.50 $522.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340136 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND BIOPSY EACH 52007 $440.00 960 $308.00 $220.00 $352.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340219 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND RADIOTRACER EACH 52250 $629.00 960 $440.30 $314.50 $503.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340227 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52260 $557.00 960 $389.90 $278.50 $445.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340334 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52290 $641.00 960 $448.70 $320.50 $512.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340169 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52214 $461.00 960 $322.70 $230.50 $368.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340177 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52224 $534.00 960 $373.80 $267.00 $427.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340185 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52234 $647.00 960 $452.90 $323.50 $517.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340193 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52235 $761.00 960 $532.70 $380.50 $608.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340201 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52240 "$1,033.00 " 960 $723.10 $516.50 $826.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340235 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52265 $432.00 960 $302.40 $216.00 $345.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340268 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52276 $695.00 960 $486.50 $347.50 $556.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340276 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52277 $851.00 960 $595.70 $425.50 $680.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340300 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52283 $531.00 960 $371.70 $265.50 $424.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340342 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52300 $737.00 960 $515.90 $368.50 $589.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340359 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52301 $764.00 960 $534.80 $382.00 $611.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340367 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52305 $732.00 960 $512.40 $366.00 $585.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340383 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52315 $723.00 960 $506.10 $361.50 $578.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340417 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52320 $647.00 960 $452.90 $323.50 $517.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340441 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52330 $693.00 960 $485.10 $346.50 $554.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340458 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52332 $411.00 960 $287.70 $205.50 $328.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340326 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY CHEMODENERVATION EACH 52287 $448.00 960 $313.60 $224.00 $358.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340292 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY IMPLANT STENT EACH 52282 $891.00 960 $623.70 $445.50 $712.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340433 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY INJECT MATERIAL EACH 52327 $682.00 960 $477.40 $341.00 $545.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340110 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY REMOVAL OF CLOTS EACH 52001 $757.00 960 $529.90 $378.50 $605.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340425 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY STONE REMOVAL EACH 52325 $842.00 960 $589.40 $421.00 $673.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340151 PHYSICIAN FEE - SURGERY PF-CYSTOSCOPY W/BIOPSY(S) EACH 52204 $374.00 960 $261.80 $187.00 $299.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340128 PHYSICIAN FEE - SURGERY PF-CYSTOSCPY & URETER CATHETER EACH 52005 $352.00 960 $246.40 $176.00 $281.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340532 PHYSICIAN FEE - SURGERY PF-CYSTOURETER & OR PYELOSCOPE EACH 52351 $799.00 960 $559.30 $399.50 $639.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340565 PHYSICIAN FEE - SURGERY PF-CYSTOURETERO W/BIOPSY EACH 52354 "$1,098.00 " 960 $768.60 $549.00 $878.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340599 PHYSICIAN FEE - SURGERY PF-CYSTOURETERO W/CONGEN REPR EACH 52400 "$1,269.00 " 960 $888.30 $634.50 "$1,015.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340573 PHYSICIAN FEE - SURGERY PF-CYSTOURETERO W/EXCISE TUMOR EACH 52355 "$1,231.00 " 960 $861.70 $615.50 $984.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340557 PHYSICIAN FEE - SURGERY PF-CYSTOURETERO W/LITHOTRIPSY EACH 52353 "$1,032.00 " 960 $722.40 $516.00 $825.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340524 PHYSICIAN FEE - SURGERY PF-CYSTOURETERO W/RENAL STRICT EACH 52346 "$1,176.00 " 960 $823.20 $588.00 $940.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340540 PHYSICIAN FEE - SURGERY PF-CYSTOURETERO W/STONE REMOVE EACH 52352 $932.00 960 $652.40 $466.00 $745.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340607 PHYSICIAN FEE - SURGERY PF-CYSTOURETHR CUT EJACUL DUCT EACH 52402 $700.00 960 $490.00 $350.00 $560.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357064 PHYSICIAN FEE - SURGERY PF-CYSTOURETHRO W/ADDL IMPLANT EACH 52442 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357056 PHYSICIAN FEE - SURGERY PF-CYSTOURETHRO W/IMPLANT EACH 52441 $552.00 960 $386.40 $276.00 $441.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345077 PHYSICIAN FEE - SURGERY PF-D & C AFTER DELIVERY EACH 59160 $545.00 960 $381.50 $272.50 $436.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343783 PHYSICIAN FEE - SURGERY PF-D&C OF CERVICAL STUMP EACH 57558 $349.00 960 $244.30 $174.50 $279.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300247 PHYSICIAN FEE - SURGERY PF-DEB BONE 20 SQ CM/< EACH 11044 $612.00 960 $428.40 $306.00 $489.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300270 PHYSICIAN FEE - SURGERY PF-DEB BONE ADD-ON EACH 11047 $268.00 960 $187.60 $134.00 $214.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300239 PHYSICIAN FEE - SURGERY PF-DEB MUSC/FASCIA 20 SQ CM/< EACH 11043 $413.00 960 $289.10 $206.50 $330.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300262 PHYSICIAN FEE - SURGERY PF-DEB MUSC/FASCIA ADD-ON EACH 11046 $151.00 960 $105.70 $75.50 $120.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300213 PHYSICIAN FEE - SURGERY PF-DEB SKIN BONE AT FX SITE EACH 11012 "$1,139.00 " 960 $797.30 $569.50 $911.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300221 PHYSICIAN FEE - SURGERY PF-DEB SUBQ TISSUE 20 SQ CM/< EACH 11042 $161.00 960 $112.70 $80.50 $128.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300254 PHYSICIAN FEE - SURGERY PF-DEB SUBQ TISSUE ADD-ON EACH 11045 $69.00 960 $48.30 $34.50 $55.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300163 PHYSICIAN FEE - SURGERY PF-DEBRIDE ABDOM WALL EACH 11005 "$2,182.00 " 960 "$1,527.40 " "$1,091.00 " "$1,745.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300171 PHYSICIAN FEE - SURGERY PF-DEBRIDE GENIT/PER/ABD WALL EACH 11006 "$1,952.00 " 960 "$1,366.40 " $976.00 "$1,561.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300155 PHYSICIAN FEE - SURGERY PF-DEBRIDE GENITALIA & PERIN EACH 11004 "$1,566.00 " 960 "$1,096.20 " $783.00 "$1,252.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300908 PHYSICIAN FEE - SURGERY PF-DEBRIDE NAIL 1-5 EACH 11720 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300916 PHYSICIAN FEE - SURGERY PF-DEBRIDE NAIL 6 OR MORE EACH 11721 $62.00 960 $43.40 $31.00 $49.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300205 PHYSICIAN FEE - SURGERY PF-DEBRIDE SKIN MSC AT FX SITE EACH 11011 $817.00 960 $571.90 $408.50 $653.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346059 PHYSICIAN FEE - SURGERY PF-DECOMPRESS EYE SOCKET EACH 61330 "$5,410.00 " 960 "$3,787.00 " "$2,705.00 " "$4,328.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311335 PHYSICIAN FEE - SURGERY PF-DECOMPRESS FINGERS/HAND EACH 26037 "$1,545.00 " 960 "$1,081.50 " $772.50 "$1,236.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311327 PHYSICIAN FEE - SURGERY PF-DECOMPRESS FINGERS/HAND EACH 26035 "$2,370.00 " 960 "$1,659.00 " "$1,185.00 " "$1,896.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309719 PHYSICIAN FEE - SURGERY PF-DECOMPRESS FOREARM 1 SPACE EACH 25020 "$1,966.00 " 960 "$1,376.20 " $983.00 "$1,572.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309727 PHYSICIAN FEE - SURGERY PF-DECOMPRESS FOREARM 1 SPACE EACH 25023 "$3,524.00 " 960 "$2,466.80 " "$1,762.00 " "$2,819.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309735 PHYSICIAN FEE - SURGERY PF-DECOMPRESS FOREARM 2 SPACES EACH 25024 "$2,147.00 " 960 "$1,502.90 " "$1,073.50 " "$1,717.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309743 PHYSICIAN FEE - SURGERY PF-DECOMPRESS FOREARM 2 SPACES EACH 25025 "$3,380.00 " 960 "$2,366.00 " "$1,690.00 " "$2,704.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352628 PHYSICIAN FEE - SURGERY PF-DECOMPRESS OPTIC NERVE EACH 67570 "$3,253.00 " 960 "$2,277.10 " "$1,626.50 " "$2,602.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333552 PHYSICIAN FEE - SURGERY PF-DECOMPRESS SMALL BOWEL EACH 44021 "$2,740.00 " 960 "$1,918.00 " "$1,370.00 " "$2,192.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348261 PHYSICIAN FEE - SURGERY PF-DECOMPRESS SPINAL CORD EACH 63055 "$4,813.00 " 960 "$3,369.10 " "$2,406.50 " "$3,850.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348279 PHYSICIAN FEE - SURGERY PF-DECOMPRESS SPINAL CORD EACH 63056 "$4,348.00 " 960 "$3,043.60 " "$2,174.00 " "$3,478.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348295 PHYSICIAN FEE - SURGERY PF-DECOMPRESS SPINAL CORD EACH 63064 "$5,245.00 " 960 "$3,671.50 " "$2,622.50 " "$4,196.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348287 PHYSICIAN FEE - SURGERY PF-DECOMPRESS SPINE CORD ADDON EACH 63057 $945.00 960 $661.50 $472.50 $756.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348303 PHYSICIAN FEE - SURGERY PF-DECOMPRESS SPINE CORD ADDON EACH 63066 $623.00 960 $436.10 $311.50 $498.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309263 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF FOREARM EACH 24495 "$2,465.00 " 960 "$1,725.50 " "$1,232.50 " "$1,972.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316771 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF LEG EACH 27892 "$1,478.00 " 960 "$1,034.60 " $739.00 "$1,182.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316789 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF LEG EACH 27893 "$1,693.00 " 960 "$1,185.10 " $846.50 "$1,354.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316797 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF LEG EACH 27894 "$2,259.00 " 960 "$1,581.30 " "$1,129.50 " "$1,807.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315575 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF LOWER LEG EACH 27600 "$1,104.00 " 960 $772.80 $552.00 $883.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315583 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF LOWER LEG EACH 27601 "$1,213.00 " 960 $849.10 $606.50 $970.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315591 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF LOWER LEG EACH 27602 "$1,338.00 " 960 $936.60 $669.00 "$1,070.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315146 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF THIGH/KNEE EACH 27496 "$1,514.00 " 960 "$1,059.80 " $757.00 "$1,211.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315153 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF THIGH/KNEE EACH 27497 "$1,606.00 " 960 "$1,124.20 " $803.00 "$1,284.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315161 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF THIGH/KNEE EACH 27498 "$1,813.00 " 960 "$1,269.10 " $906.50 "$1,450.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315179 PHYSICIAN FEE - SURGERY PF-DECOMPRESSION OF THIGH/KNEE EACH 27499 "$1,938.00 " 960 "$1,356.60 " $969.00 "$1,550.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346034 PHYSICIAN FEE - SURGERY PF-DECOMPRESSIVE CRANIOTOMY EACH 61322 "$7,189.00 " 960 "$5,032.30 " "$3,594.50 " "$5,751.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346042 PHYSICIAN FEE - SURGERY PF-DECOMPRESSIVE LOBECTOMY EACH 61323 "$7,228.00 " 960 "$5,059.60 " "$3,614.00 " "$5,782.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303977 PHYSICIAN FEE - SURGERY PF-DEEP MUSCLE BIOPSY EACH 20205 $441.00 960 $308.70 $220.50 $352.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303761 PHYSICIAN FEE - SURGERY PF-DELAYED BREAST PROSTHESIS EACH 19342 "$2,066.00 " 960 "$1,446.20 " "$1,033.00 " "$1,652.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313166 PHYSICIAN FEE - SURGERY PF-DENERVATION OF HIP JOINT EACH 27035 "$2,892.00 " 960 "$2,024.40 " "$1,446.00 " "$2,313.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301963 PHYSICIAN FEE - SURGERY PF-DERM AUTOGRAFT F/N/HF/G ADD EACH 15136 $242.00 960 $169.40 $121.00 $193.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301948 PHYSICIAN FEE - SURGERY PF-DERM AUTOGRAFT T/A/L ADD-ON EACH 15131 $242.00 960 $169.40 $121.00 $193.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301930 PHYSICIAN FEE - SURGERY PF-DERM AUTOGRAFT TRNK/ARM/LEG EACH 15130 "$1,609.00 " 960 "$1,126.30 " $804.50 "$1,287.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301955 PHYSICIAN FEE - SURGERY PF-DERM AUTOGRFT FACE/NCK/HF/G EACH 15135 "$2,017.00 " 960 "$1,411.90 " "$1,008.50 " "$1,613.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302441 PHYSICIAN FEE - SURGERY PF-DERMABRASION FACE SEGMENTAL EACH 15781 "$1,133.00 " 960 $793.10 $566.50 $906.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302391 PHYSICIAN FEE - SURGERY PF-DERMA-FAT-FASCIA GRAFT EACH 15770 "$1,808.00 " 960 "$1,265.60 " $904.00 "$1,446.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357262 PHYSICIAN FEE - SURGERY PF-DERMAL FILLER INJECTION(S) EACH G0429 $181.00 960 $126.70 $90.50 $144.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357684 PHYSICIAN FEE - SURGERY PF-DERMATOLOGICAL PROC NOS EACH 96999 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303894 PHYSICIAN FEE - SURGERY PF-DESIGN CUSTOM BREAST IMPLNT EACH 19396 $388.00 960 $271.60 $194.00 $310.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303159 PHYSICIAN FEE - SURGERY PF-DEST LES MAL SC/HD TO 0.5CM EACH 17270 $251.00 960 $175.70 $125.50 $200.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303092 PHYSICIAN FEE - SURGERY PF-DEST LES MAL TRNK/ARM TO .5 EACH 17260 $185.00 960 $129.50 $92.50 $148.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303266 PHYSICIAN FEE - SURGERY PF-DEST LESN MAL FACE/EAR >4CM EACH 17286 $707.00 960 $494.90 $353.50 $565.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303167 PHYSICIAN FEE - SURGERY PF-DEST LESN MAL SC/HD .6-1.0 EACH 17271 $275.00 960 $192.50 $137.50 $220.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303209 PHYSICIAN FEE - SURGERY PF-DEST LESN MAL SC/HD >4.0CM EACH 17276 $530.00 960 $371.00 $265.00 $424.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303175 PHYSICIAN FEE - SURGERY PF-DEST LESN MAL SC/HD 1.1-2.0 EACH 17272 $318.00 960 $222.60 $159.00 $254.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303183 PHYSICIAN FEE - SURGERY PF-DEST LESN MAL SC/HD 2.1-3.0 EACH 17273 $359.00 960 $251.30 $179.50 $287.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303191 PHYSICIAN FEE - SURGERY PF-DEST LESN MAL SC/HD 3.1-4.0 EACH 17274 $438.00 960 $306.60 $219.00 $350.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303100 PHYSICIAN FEE - SURGERY PF-DEST LESN MAL TR/A 0.6-1.0 EACH 17261 $229.00 960 $160.30 $114.50 $183.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303118 PHYSICIAN FEE - SURGERY PF-DEST LESN MAL TR/A 1.1-2.0 EACH 17262 $289.00 960 $202.30 $144.50 $231.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303134 PHYSICIAN FEE - SURGERY PF-DEST LESN MAL TR/A 3.0-4.0 EACH 17264 $342.00 960 $239.40 $171.00 $273.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349954 PHYSICIAN FEE - SURGERY PF-DEST NRV HYPOGASTRIC PLEXUS EACH 64681 $570.00 960 $399.00 $285.00 $456.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356900 PHYSICIAN FEE - SURGERY PF-DESTR L/S FACET JNT ADDL BI EACH 64636 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356819 PHYSICIAN FEE - SURGERY PF-DESTROY C/T FACET JNT BI EACH 64633 $503.00 960 $352.10 $251.50 $402.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356843 PHYSICIAN FEE - SURGERY PF-DESTROY C/T FACET JNT BI EACH 64634 $176.00 960 $123.20 $88.00 $140.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336035 PHYSICIAN FEE - SURGERY PF-DESTROY INTERN HEMORRHOIDS EACH 46930 $401.00 960 $280.70 $200.50 $320.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356876 PHYSICIAN FEE - SURGERY PF-DESTROY L/S FACET JNT BI EACH 64635 $504.00 960 $352.80 $252.00 $403.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303027 PHYSICIAN FEE - SURGERY PF-DESTROY PREMLG LESIONS 15+ EACH 17004 $258.00 960 $180.60 $129.00 $206.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343007 PHYSICIAN FEE - SURGERY PF-DESTROY VAG LESIONS COMPLEX EACH 57065 $504.00 960 $352.80 $252.00 $403.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342751 PHYSICIAN FEE - SURGERY PF-DESTROY VULVA LESION/S CMPL EACH 56515 $576.00 960 $403.20 $288.00 $460.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342744 PHYSICIAN FEE - SURGERY PF-DESTROY VULVA LESIONS SIM EACH 56501 $357.00 960 $249.90 $178.50 $285.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303068 PHYSICIAN FEE - SURGERY PF-DESTRUCT B9 LESION 1-14 EACH 17110 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303076 PHYSICIAN FEE - SURGERY PF-DESTRUCT LESION 15 OR MORE EACH 17111 $218.00 960 $152.60 $109.00 $174.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303019 PHYSICIAN FEE - SURGERY PF-DESTRUCT PREMALG LES 2-14 EACH 17003 $5.00 960 $3.50 $2.50 $4.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335979 PHYSICIAN FEE - SURGERY PF-DESTRUCTION ANAL LESION(S) EACH 46900 $367.00 960 $256.90 $183.50 $293.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335987 PHYSICIAN FEE - SURGERY PF-DESTRUCTION ANAL LESION(S) EACH 46910 $367.00 960 $256.90 $183.50 $293.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336027 PHYSICIAN FEE - SURGERY PF-DESTRUCTION ANAL LESION(S) EACH 46924 $489.00 960 $342.30 $244.50 $391.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351711 PHYSICIAN FEE - SURGERY PF-DESTRUCTION CILIARY BODY EACH 66700 "$1,002.00 " 960 $701.40 $501.00 $801.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303043 PHYSICIAN FEE - SURGERY PF-DESTRUCTION OF SKIN LESIONS EACH 17107 $943.00 960 $660.10 $471.50 $754.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341340 PHYSICIAN FEE - SURGERY PF-DESTRUCTION PENIS LESION(S) EACH 54065 $451.00 960 $315.70 $225.50 $360.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341308 PHYSICIAN FEE - SURGERY PF-DESTRUCTION PENIS LESION(S) EACH 54055 $254.00 960 $177.80 $127.00 $203.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334832 PHYSICIAN FEE - SURGERY PF-DESTRUCTION RECTAL TUMOR EACH 45190 "$1,872.00 " 960 "$1,310.40 " $936.00 "$1,497.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334048 PHYSICIAN FEE - SURGERY PF-DEVISE BOWEL POUCH EACH 44316 "$4,021.00 " 960 "$2,814.70 " "$2,010.50 " "$3,216.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321557 PHYSICIAN FEE - SURGERY PF-DIAG BRONCHOSCOPE/CATHETER EACH 31643 $433.00 960 $303.10 $216.50 $346.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337314 PHYSICIAN FEE - SURGERY PF-DIAG LAPARO SEPARATE PROC EACH 49320 $926.00 960 $648.20 $463.00 $740.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335664 PHYSICIAN FEE - SURGERY PF-DIAGNOSTIC ANOSCOPY EACH 46600 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335060 PHYSICIAN FEE - SURGERY PF-DIAGNOSTIC COLONOSCOPY EACH 45378 $244.00 960 $170.80 $122.00 $195.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321136 PHYSICIAN FEE - SURGERY PF-DIAGNOSTIC LARYNGOSCOPY EACH 31575 $183.00 960 $128.10 $91.50 $146.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321177 PHYSICIAN FEE - SURGERY PF-DIAGNOSTIC LARYNGOSCOPY EACH 31579 $318.00 960 $222.60 $159.00 $254.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334956 PHYSICIAN FEE - SURGERY PF-DIAGNOSTIC SIGMOIDOSCOPY EACH 45330 $151.00 960 $105.70 $75.50 $120.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359680 PHYSICIAN FEE - SURGERY PF-DIALYSIS CIRCUIT EMBOLJ EACH 36909 $540.00 960 $378.00 $270.00 $432.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350259 PHYSICIAN FEE - SURGERY PF-DIGIT NERVE SURGERY ADD-ON EACH 64778 $497.00 960 $347.90 $248.50 $397.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360134 PHYSICIAN FEE - SURGERY PF-DILAT XST TRC NDURLGC PX EACH 50436 $387.00 960 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360142 PHYSICIAN FEE - SURGERY PF-DILAT XST TRC NEW ACCESS RC EACH 50437 $640.00 960 $448.00 $320.00 $512.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358906 PHYSICIAN FEE - SURGERY PF-DILATE BILIARY DUCT/AMPULLA EACH 47542 $350.00 960 $245.00 $175.00 $280.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332851 PHYSICIAN FEE - SURGERY PF-DILATE ESOPHAGUS EACH 43453 $230.00 960 $161.00 $115.00 $184.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332844 PHYSICIAN FEE - SURGERY PF-DILATE ESOPHAGUS EACH 43450 $210.00 960 $147.00 $105.00 $168.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353451 PHYSICIAN FEE - SURGERY PF-DILATE TEAR DUCT OPENING EACH 68801 $203.00 960 $142.10 $101.50 $162.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341142 PHYSICIAN FEE - SURGERY PF-DILATE URETHRA STRICTURE EACH 53600 $169.00 960 $118.30 $84.50 $135.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341159 PHYSICIAN FEE - SURGERY PF-DILATE URETHRA STRICTURE EACH 53601 $141.00 960 $98.70 $70.50 $112.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341167 PHYSICIAN FEE - SURGERY PF-DILATE URETHRA STRICTURE EACH 53605 $170.00 960 $119.00 $85.00 $136.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341175 PHYSICIAN FEE - SURGERY PF-DILATE URETHRA STRICTURE EACH 53620 $231.00 960 $161.70 $115.50 $184.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341183 PHYSICIAN FEE - SURGERY PF-DILATE URETHRA STRICTURE EACH 53621 $191.00 960 $133.70 $95.50 $152.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335342 PHYSICIAN FEE - SURGERY PF-DILATION OF ANAL SPHINCTER EACH 45905 $462.00 960 $323.40 $231.00 $369.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331366 PHYSICIAN FEE - SURGERY PF-DILATION OF SALIVARY DUCT EACH 42650 $158.00 960 $110.60 $79.00 $126.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331374 PHYSICIAN FEE - SURGERY PF-DILATION OF SALIVARY DUCT EACH 42660 $239.00 960 $167.30 $119.50 $191.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341191 PHYSICIAN FEE - SURGERY PF-DILATION OF URETHRA EACH 53660 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341209 PHYSICIAN FEE - SURGERY PF-DILATION OF URETHRA EACH 53661 $107.00 960 $74.90 $53.50 $85.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341217 PHYSICIAN FEE - SURGERY PF-DILATION OF URETHRA EACH 53665 $101.00 960 $70.70 $50.50 $80.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343502 PHYSICIAN FEE - SURGERY PF-DILATION OF VAGINA EACH 57400 $357.00 960 $249.90 $178.50 $285.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335359 PHYSICIAN FEE - SURGERY PF-DILATION RECTAL NARROWING EACH 45910 $523.00 960 $366.10 $261.50 $418.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360936 PHYSICIAN FEE - SURGERY PF-DISE EVL SLP DO BRTH FLX DX EACH 42975 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347529 PHYSICIAN FEE - SURGERY PF-DISSECT BRAIN W/SCOPE EACH 62161 "$4,594.00 " 960 "$3,215.80 " "$2,297.00 " "$3,675.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328628 PHYSICIAN FEE - SURGERY PF-DIST REVAS LIGATION HEMO EACH 36838 "$3,209.00 " 960 "$2,246.30 " "$1,604.50 " "$2,567.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344450 PHYSICIAN FEE - SURGERY PF-DIVISION OF FALLOPIAN TUBE EACH 58600 "$1,015.00 " 960 $710.50 $507.50 $812.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344468 PHYSICIAN FEE - SURGERY PF-DIVISION OF FALLOPIAN TUBE EACH 58605 $922.00 960 $645.40 $461.00 $737.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312424 PHYSICIAN FEE - SURGERY PF-DOUBLE TRANSFER TOE-HAND EACH 26554 "$10,454.00 " 960 "$7,317.80 " "$5,227.00 " "$8,363.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353543 PHYSICIAN FEE - SURGERY PF-DRAIN ABSC EXT AUDITRY CANL EACH 69020 $382.00 960 $267.40 $191.00 $305.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319841 PHYSICIAN FEE - SURGERY PF-DRAIN ABSC/HEMAT NASAL SEPT EACH 30020 $328.00 960 $229.60 $164.00 $262.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334550 PHYSICIAN FEE - SURGERY PF-DRAIN APP ABSCESS OPEN EACH 44900 "$2,224.00 " 960 "$1,556.80 " "$1,112.00 " "$1,779.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308570 PHYSICIAN FEE - SURGERY PF-DRAIN ARM/ELBOW BONE LESION EACH 23935 "$1,414.00 " 960 $989.80 $707.00 "$1,131.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339542 PHYSICIAN FEE - SURGERY PF-DRAIN BL W/CATH INSERTION EACH 51102 $376.00 960 $263.20 $188.00 $300.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339534 PHYSICIAN FEE - SURGERY PF-DRAIN BLADDER TROCAR/CATH EACH 51101 $136.00 960 $95.20 $68.00 $108.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300940 PHYSICIAN FEE - SURGERY PF-DRAIN BLOOD FROM UNDER NAIL EACH 11740 $84.00 960 $58.80 $42.00 $67.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303365 PHYSICIAN FEE - SURGERY PF-DRAIN BREAST LESION ADD-ON EACH 19001 $56.00 960 $39.20 $28.00 $44.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306319 PHYSICIAN FEE - SURGERY PF-DRAIN CHEST LESION EACH 21502 "$1,423.00 " 960 $996.10 $711.50 "$1,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353527 PHYSICIAN FEE - SURGERY PF-DRAIN EXTERNAL EAR LESION EACH 69000 $335.00 960 $234.50 $167.50 $268.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353535 PHYSICIAN FEE - SURGERY PF-DRAIN EXTERNAL EAR LESION EACH 69005 $434.00 960 $303.80 $217.00 $347.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311285 PHYSICIAN FEE - SURGERY PF-DRAIN HAND TENDON SHEATH EACH 26020 "$1,523.00 " 960 "$1,066.10 " $761.50 "$1,218.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315617 PHYSICIAN FEE - SURGERY PF-DRAIN LOWER LEG BURSA EACH 27604 $873.00 960 $611.10 $436.50 $698.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315609 PHYSICIAN FEE - SURGERY PF-DRAIN LOWER LEG LESION DEEP EACH 27603 "$1,061.00 " 960 $742.70 $530.50 $848.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306301 PHYSICIAN FEE - SURGERY PF-DRAIN NECK/CHEST LESION EACH 21501 $920.00 960 $644.00 $460.00 $736.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337173 PHYSICIAN FEE - SURGERY PF-DRAIN OPEN ABDOM ABSCESS EACH 49040 "$2,823.00 " 960 "$1,976.10 " "$1,411.50 " "$2,258.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321979 PHYSICIAN FEE - SURGERY PF-DRAIN OPEN LUNG LESION EACH 32200 "$3,189.00 " 960 "$2,232.30 " "$1,594.50 " "$2,551.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337181 PHYSICIAN FEE - SURGERY PF-DRAIN OPEN RETROP ABSCESS EACH 49060 "$3,065.00 " 960 "$2,145.50 " "$1,532.50 " "$2,452.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344658 PHYSICIAN FEE - SURGERY PF-DRAIN OVARY ABSCESS OPEN EACH 58820 $920.00 960 $644.00 $460.00 $736.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344666 PHYSICIAN FEE - SURGERY PF-DRAIN OVARY ABSCESS PERCUT EACH 58822 "$1,628.00 " 960 "$1,139.60 " $814.00 "$1,302.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337033 PHYSICIAN FEE - SURGERY PF-DRAIN PANCREATIC PSEUDOCYST EACH 48510 "$3,099.00 " 960 "$2,169.30 " "$1,549.50 " "$2,479.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341282 PHYSICIAN FEE - SURGERY PF-DRAIN PENIS LESION EACH 54015 $811.00 960 $567.70 $405.50 $648.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307580 PHYSICIAN FEE - SURGERY PF-DRAIN SHOULDER BONE LESION EACH 23035 "$1,866.00 " 960 "$1,306.20 " $933.00 "$1,492.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307572 PHYSICIAN FEE - SURGERY PF-DRAIN SHOULDER BURSA EACH 23031 $610.00 960 $427.00 $305.00 $488.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307564 PHYSICIAN FEE - SURGERY PF-DRAIN SHOULDER LESION EACH 23030 $700.00 960 $490.00 $350.00 $560.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347735 PHYSICIAN FEE - SURGERY PF-DRAIN SPINAL CORD CYST EACH 62268 $988.00 960 $691.60 $494.00 $790.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314230 PHYSICIAN FEE - SURGERY PF-DRAIN THIGH/KNEE LESION EACH 27301 "$1,407.00 " 960 $984.90 $703.50 "$1,125.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345465 PHYSICIAN FEE - SURGERY PF-DRAIN THYROID/TONGUE CYST EACH 60000 $421.00 960 $294.70 $210.50 $336.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337199 PHYSICIAN FEE - SURGERY PF-DRAIN TO PERITONEAL CAVITY EACH 49062 "$2,182.00 " 960 "$1,527.40 " "$1,091.00 " "$1,745.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329576 PHYSICIAN FEE - SURGERY PF-DRAINAGE LYMPH NODE LESION EACH 38300 $579.00 960 $405.30 $289.50 $463.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329584 PHYSICIAN FEE - SURGERY PF-DRAINAGE LYMPH NODE LESION EACH 38305 "$1,388.00 " 960 $971.60 $694.00 "$1,110.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330889 PHYSICIAN FEE - SURGERY PF-DRAINAGE MOUTH ROOF LESION EACH 42000 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308562 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF ARM BURSA EACH 23931 $439.00 960 $307.30 $219.50 $351.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308554 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF ARM LESION EACH 23930 $595.00 960 $416.50 $297.50 $476.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339518 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF BLADDER ABSCESS EACH 51080 "$1,089.00 " 960 $762.30 $544.50 $871.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306327 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF BONE LESION EACH 21510 "$1,263.00 " 960 $884.10 $631.50 "$1,010.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313067 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF BONE LESION EACH 26992 "$2,770.00 " 960 "$1,939.00 " "$1,385.00 " "$2,216.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314248 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF BONE LESION EACH 27303 "$1,769.00 " 960 "$1,238.30 " $884.50 "$1,415.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316805 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF BURSA OF FOOT EACH 28001 $251.00 960 $175.70 $125.50 $200.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351349 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF EYE EACH 65815 "$1,218.00 " 960 $852.60 $609.00 $974.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311269 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF FINGER ABSCESS EACH 26010 $380.00 960 $266.00 $190.00 $304.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311277 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF FINGER ABSCESS EACH 26011 $502.00 960 $351.40 $251.00 $401.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309768 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF FOREARM BURSA EACH 25031 "$1,017.00 " 960 $711.90 $508.50 $813.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309750 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF FOREARM LESION EACH 25028 "$1,841.00 " 960 "$1,288.70 " $920.50 "$1,472.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330764 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF GUM LESION EACH 41800 $407.00 960 $284.90 $203.50 $325.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313141 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF HIP JOINT EACH 27030 "$2,580.00 " 960 "$1,806.00 " "$1,290.00 " "$2,064.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338148 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF KIDNEY EACH 50040 "$2,454.00 " 960 "$1,717.80 " "$1,227.00 " "$1,963.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330202 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 40801 $520.00 960 $364.00 $260.00 $416.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330392 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 41000 $274.00 960 $191.80 $137.00 $219.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330400 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 41005 $303.00 960 $212.10 $151.50 $242.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330418 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 41006 $606.00 960 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330426 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 41007 $579.00 960 $405.30 $289.50 $463.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330434 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 41008 $681.00 960 $476.70 $340.50 $544.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330442 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 41009 $752.00 960 $526.40 $376.00 $601.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330475 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 41016 $901.00 960 $630.70 $450.50 $720.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330483 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 41017 $894.00 960 $625.80 $447.00 $715.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330491 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF MOUTH LESION EACH 41018 "$1,047.00 " 960 $732.90 $523.50 $837.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344633 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF OVARIAN CYST(S) EACH 58800 $859.00 960 $601.30 $429.50 $687.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344641 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF OVARIAN CYST(S) EACH 58805 "$1,169.00 " 960 $818.30 $584.50 $935.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311293 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF PALM BURSA EACH 26025 "$1,151.00 " 960 $805.70 $575.50 $920.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311301 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF PALM BURSA(S) EACH 26030 "$1,350.00 " 960 $945.00 $675.00 "$1,080.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334600 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF PELVIC ABSCESS EACH 45000 "$1,172.00 " 960 $820.40 $586.00 $937.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342959 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF PELVIC ABSCESS EACH 57010 "$1,248.00 " 960 $873.60 $624.00 $998.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342967 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF PELVIC FLUID EACH 57020 $217.00 960 $151.90 $108.50 $173.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313059 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF PELVIS BURSA EACH 26991 "$1,458.00 " 960 "$1,020.60 " $729.00 "$1,166.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313042 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF PELVIS LESION EACH 26990 "$1,860.00 " 960 "$1,302.00 " $930.00 "$1,488.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334626 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF RECTAL ABSCESS EACH 45020 "$1,556.00 " 960 "$1,089.20 " $778.00 "$1,244.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331218 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF SALIVARY CYST EACH 42409 $622.00 960 $435.40 $311.00 $497.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331119 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF SALIVARY GLAND EACH 42300 $418.00 960 $292.60 $209.00 $334.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331127 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF SALIVARY GLAND EACH 42305 "$1,167.00 " 960 $816.90 $583.50 $933.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342256 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF SCROTUM ABSCESS EACH 55100 $451.00 960 $315.70 $225.50 $360.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300056 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF SKIN ABSCESS EACH 10061 $489.00 960 $342.30 $244.50 $391.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348477 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF SPINAL CYST EACH 63172 "$4,261.00 " 960 "$2,982.70 " "$2,130.50 " "$3,408.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348485 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF SPINAL CYST EACH 63173 "$5,209.00 " 960 "$3,646.30 " "$2,604.50 " "$4,167.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331408 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF THROAT ABSCESS EACH 42720 "$1,038.00 " 960 $726.60 $519.00 $830.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331416 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF THROAT ABSCESS EACH 42725 "$2,155.00 " 960 "$1,508.50 " "$1,077.50 " "$1,724.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331390 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF TONSIL ABSCESS EACH 42700 $364.00 960 $254.80 $182.00 $291.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340755 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF URETHRA ABSCESS EACH 53060 $452.00 960 $316.40 $226.00 $361.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340763 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF URINARY LEAKAGE EACH 53080 "$1,121.00 " 960 $784.70 $560.50 $896.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340771 PHYSICIAN FEE - SURGERY PF-DRAINAGE OF URINARY LEAKAGE EACH 53085 "$1,722.00 " 960 "$1,205.40 " $861.00 "$1,377.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340698 PHYSICIAN FEE - SURGERY PF-DRAINAGE PROSTATE ABSCESS EACH 52700 "$1,179.00 " 960 $825.30 $589.50 $943.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342496 PHYSICIAN FEE - SURGERY PF-DRAINAGE PROSTATE ABSCESS EACH 55720 "$1,205.00 " 960 $843.50 $602.50 $964.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342504 PHYSICIAN FEE - SURGERY PF-DRAINAGE PROSTATE ABSCESS EACH 55725 "$1,586.00 " 960 "$1,110.20 " $793.00 "$1,268.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328354 PHYSICIAN FEE - SURGERY PF-DRAW BLOOD OFF VENOUS DEV EACH 36591 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302979 PHYSICIAN FEE - SURGERY PF-DRESS/DEBRID P-THICK BURN L EACH 16030 $363.00 960 $254.10 $181.50 $290.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302961 PHYSICIAN FEE - SURGERY PF-DRESS/DEBRID P-THICK BURN M EACH 16025 $302.00 960 $211.40 $151.00 $241.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302953 PHYSICIAN FEE - SURGERY PF-DRESS/DEBRID P-THICK BURN S EACH 16020 $150.00 960 $105.00 $75.00 $120.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345838 PHYSICIAN FEE - SURGERY PF-DRILL SKULL FOR DRAINAGE EACH 61108 "$2,685.00 " 960 "$1,879.50 " "$1,342.50 " "$2,148.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337074 PHYSICIAN FEE - SURGERY PF-DUODENAL EXCLUSION EACH 48547 "$5,091.00 " 960 "$3,563.70 " "$2,545.50 " "$4,072.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357759 PHYSICIAN FEE - SURGERY PF-DX ANOSCOPY & BIOPSY EACH 46607 $335.00 960 $234.50 $167.50 $268.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321375 PHYSICIAN FEE - SURGERY PF-DX BRONCHOSCOPE/BRUSH EACH 31623 $340.00 960 $238.00 $170.00 $272.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321383 PHYSICIAN FEE - SURGERY PF-DX BRONCHOSCOPE/LAVAGE EACH 31624 $345.00 960 $241.50 $172.50 $276.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321367 PHYSICIAN FEE - SURGERY PF-DX BRONCHOSCOPE/WASH EACH 31622 $349.00 960 $244.30 $174.50 $279.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333172 PHYSICIAN FEE - SURGERY PF-DX DUOD INTUB W/ASP SPEC EACH 43756 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333180 PHYSICIAN FEE - SURGERY PF-DX DUOD INTUB W/ASP SPECS EACH 43757 $203.00 960 $142.10 $101.50 $162.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333156 PHYSICIAN FEE - SURGERY PF-DX GASTR INTUB W/ASP SPEC EACH 43754 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333164 PHYSICIAN FEE - SURGERY PF-DX GASTR INTUB W/ASP SPECS EACH 43755 $157.00 960 $109.90 $78.50 $125.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320963 PHYSICIAN FEE - SURGERY PF-DX LARYNGOSCOPY EXCL NB EACH 31525 $430.00 960 $301.00 $215.00 $344.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320955 PHYSICIAN FEE - SURGERY PF-DX LARYNGOSCOPY NEWBORN EACH 31520 $420.00 960 $294.00 $210.00 $336.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320971 PHYSICIAN FEE - SURGERY PF-DX LARYNGOSCPY W/OPER SCOPE EACH 31526 $421.00 960 $294.70 $210.50 $336.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361553 PHYSICIAN FEE - SURGERY PF-DX LMBR SPI PNXR W/FLUOR/CT EACH 62328 $223.00 960 $156.10 $111.50 $178.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341555 PHYSICIAN FEE - SURGERY PF-DYNAMIC CAVERNOSOMETRY EACH 54231 $306.00 960 $214.20 $153.00 $244.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305519 PHYSICIAN FEE - SURGERY PF-EAR CARTILAGE GRAFT EACH 21235 "$1,521.00 " 960 "$1,064.70 " $760.50 "$1,216.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354715 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS DAILY MGMT ARTERY EACH 33949 $631.00 960 $441.70 $315.50 $504.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354707 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS DAILY MGMT-VENOUS EACH 33948 $643.00 960 $450.10 $321.50 $514.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354699 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS INITIATION ARTERY EACH 33947 $950.00 960 $665.00 $475.00 $760.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354681 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS INITIATION VENOUS EACH 33946 $857.00 960 $599.90 $428.50 $685.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354764 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS INSJ CTR CANNULA EACH 33955 "$2,297.00 " 960 "$1,607.90 " "$1,148.50 " "$1,837.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354772 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS INSJ CTR CANNULA EACH 33956 "$2,343.00 " 960 "$1,640.10 " "$1,171.50 " "$1,874.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354731 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS INSJ PRPH CANNULA EACH 33952 "$1,186.00 " 960 $830.20 $593.00 $948.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354723 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS INSJ PRPH CANNULA EACH 33951 "$1,173.00 " 960 $821.10 $586.50 $938.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354749 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS INSJ PRPH CANNULA EACH 33953 "$1,311.00 " 960 $917.70 $655.50 "$1,048.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354756 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS INSJ PRPH CANNULA EACH 33954 "$1,331.00 " 960 $931.70 $665.50 "$1,064.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354822 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS REPOS PERPH CNULA EACH 33963 "$1,296.00 " 960 $907.20 $648.00 "$1,036.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354830 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS REPOS PERPH CNULA EACH 33964 "$1,369.00 " 960 $958.30 $684.50 "$1,095.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354780 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS REPOS PERPH CNULA EACH 33957 $510.00 960 $357.00 $255.00 $408.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354798 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS REPOS PERPH CNULA EACH 33958 $510.00 960 $357.00 $255.00 $408.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354806 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS REPOS PERPH CNULA EACH 33959 $652.00 960 $456.40 $326.00 $521.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354814 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS REPOS PERPH CNULA EACH 33962 $652.00 960 $456.40 $326.00 $521.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354889 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS RMVL CTR CANNULA EACH 33985 "$1,423.00 " 960 $996.10 $711.50 "$1,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354897 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS RMVL CTR CANNULA EACH 33986 "$1,466.00 " 960 "$1,026.20 " $733.00 "$1,172.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354848 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS RMVL PERPH CNULA EACH 33965 $510.00 960 $357.00 $255.00 $408.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354863 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS RMVL PERPH CNULA EACH 33969 $756.00 960 $529.20 $378.00 $604.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354855 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS RMVL PRPH CANNULA EACH 33966 $660.00 960 $462.00 $330.00 $528.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354871 PHYSICIAN FEE - SURGERY PF-ECMO/ECLS RMVL PRPH CANNULA EACH 33984 $795.00 960 $556.50 $397.50 $636.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355050 PHYSICIAN FEE - SURGERY PF-EGD BALLOON DIL ESPH30 MM/> EACH 43233 $613.00 960 $429.10 $306.50 $490.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355076 PHYSICIAN FEE - SURGERY PF-EGD ENDO MUCOSAL RESECTION EACH 43254 $706.00 960 $494.20 $353.00 $564.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332398 PHYSICIAN FEE - SURGERY PF-EGD ENDOSCOPIC STENT PLACE EACH 43266 $575.00 960 $402.50 $287.50 $460.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359755 PHYSICIAN FEE - SURGERY PF-EGD ESOPHAGOGASTR FNDOPLSTY EACH 43210 "$1,162.00 " 960 $813.40 $581.00 $929.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361314 PHYSICIAN FEE - SURGERY PF-EGD FLX TRNSORL DPLMNT BALO EACH 43290 $503.00 960 $352.10 $251.50 $402.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361322 PHYSICIAN FEE - SURGERY PF-EGD FLX TRNSORL RMVL BALO EACH 43291 $424.00 960 $296.80 $212.00 $339.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332406 PHYSICIAN FEE - SURGERY PF-EGD LESION ABLATION EACH 43270 $587.00 960 $410.90 $293.50 $469.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355068 PHYSICIAN FEE - SURGERY PF-EGD OPTICAL ENDOMICROSCOPY EACH 43252 $442.00 960 $309.40 $221.00 $353.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332299 PHYSICIAN FEE - SURGERY PF-EGD US TRANSMURAL INJ/MARK EACH 43253 $686.00 960 $480.20 $343.00 $548.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319239 PHYSICIAN FEE - SURGERY PF-ELBOW ARTHROSCOPY EACH 29830 "$1,247.00 " 960 $872.90 $623.50 $997.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319247 PHYSICIAN FEE - SURGERY PF-ELBOW ARTHROSCOPY/SURGERY EACH 29834 "$1,349.00 " 960 $944.30 $674.50 "$1,079.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319254 PHYSICIAN FEE - SURGERY PF-ELBOW ARTHROSCOPY/SURGERY EACH 29835 "$1,406.00 " 960 $984.20 $703.00 "$1,124.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319262 PHYSICIAN FEE - SURGERY PF-ELBOW ARTHROSCOPY/SURGERY EACH 29836 "$1,607.00 " 960 "$1,124.90 " $803.50 "$1,285.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319270 PHYSICIAN FEE - SURGERY PF-ELBOW ARTHROSCOPY/SURGERY EACH 29837 "$1,443.00 " 960 "$1,010.10 " $721.50 "$1,154.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319288 PHYSICIAN FEE - SURGERY PF-ELBOW ARTHROSCOPY/SURGERY EACH 29838 "$1,635.00 " 960 "$1,144.50 " $817.50 "$1,308.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304652 PHYSICIAN FEE - SURGERY PF-ELECTRICAL BONE STIMULATION EACH 20974 $142.00 960 $99.40 $71.00 $113.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304660 PHYSICIAN FEE - SURGERY PF-ELECTRICAL BONE STIMULATION EACH 20975 $495.00 960 $346.50 $247.50 $396.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342645 PHYSICIAN FEE - SURGERY PF-ELECTROEJACULATION EACH 55870 $377.00 960 $263.90 $188.50 $301.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357163 PHYSICIAN FEE - SURGERY PF-ELECTROMAGNTIC TX ULCERS EACH G0329 $28.00 960 $19.60 $14.00 $22.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323272 PHYSICIAN FEE - SURGERY PF-ELTRD/INSERT PACE-DEFIB EACH 33249 "$2,506.00 " 960 "$1,754.20 " "$1,253.00 " "$2,004.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337579 PHYSICIAN FEE - SURGERY PF-EMBEDDED IP CATH EXIT-SITE EACH 49436 $523.00 960 $366.10 $261.50 $418.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332331 PHYSICIAN FEE - SURGERY PF-ENDO CHOLANGIOPANCREATOGRPH EACH 43260 $845.00 960 $591.50 $422.50 $676.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332380 PHYSICIAN FEE - SURGERY PF-ENDO CHOLANGIOPANCREATOGRPH EACH 43265 "$1,134.00 " 960 $793.80 $567.00 $907.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332349 PHYSICIAN FEE - SURGERY PF-ENDO CHOLANGIOPANCREATOGRPH EACH 43261 $888.00 960 $621.60 $444.00 $710.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332356 PHYSICIAN FEE - SURGERY PF-ENDO CHOLANGIOPANCREATOGRPH EACH 43262 $933.00 960 $653.10 $466.50 $746.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332364 PHYSICIAN FEE - SURGERY PF-ENDO CHOLANGIOPANCREATOGRPH EACH 43263 $936.00 960 $655.20 $468.00 $748.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332372 PHYSICIAN FEE - SURGERY PF-ENDO CHOLANGIOPANCREATOGRPH EACH 43264 $952.00 960 $666.40 $476.00 $761.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343619 PHYSICIAN FEE - SURGERY PF-ENDOCERV CURETTAGE W/SCOPE EACH 57456 $277.00 960 $193.90 $138.50 $221.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343650 PHYSICIAN FEE - SURGERY PF-ENDOCERVICAL CURETTAGE EACH 57505 $294.00 960 $205.80 $147.00 $235.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357510 PHYSICIAN FEE - SURGERY PF-ENDOCRINE SURGERY PROC NOS EACH 60699 "$3,531.00 " 960 "$2,471.70 " "$1,765.50 " "$2,824.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360159 PHYSICIAN FEE - SURGERY PF-ENDOLUMINAL BX URTR RNL PLV EACH 50606 $368.00 960 $257.60 $184.00 $294.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358773 PHYSICIAN FEE - SURGERY PF-ENDOLUMINL BX URTR RNL PLVS EACH 58575 "$5,283.00 " 960 "$3,698.10 " "$2,641.50 " "$4,226.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344161 PHYSICIAN FEE - SURGERY PF-ENDOMETR ABLATE THERMAL EACH 58353 $628.00 960 $439.60 $314.00 $502.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344179 PHYSICIAN FEE - SURGERY PF-ENDOMETRIAL CRYOABLATION EACH 58356 $972.00 960 $680.40 $486.00 $777.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339807 PHYSICIAN FEE - SURGERY PF-ENDOSCOPIC INJ/IMPLANT EACH 51715 $533.00 960 $373.10 $266.50 $426.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332414 PHYSICIAN FEE - SURGERY PF-ENDOSCOPIC PANCREATOSCOPY EACH 43273 $312.00 960 $218.40 $156.00 $249.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332323 PHYSICIAN FEE - SURGERY PF-ENDOSCOPIC ULTRASOUND EXAM EACH 43259 $590.00 960 $413.00 $295.00 $472.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332141 PHYSICIAN FEE - SURGERY PF-ENDOSCOPIC US EXAM ESOPH EACH 43237 $512.00 960 $358.40 $256.00 $409.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324015 PHYSICIAN FEE - SURGERY PF-ENDOSCOPIC VEIN HARVEST EACH 33508 $45.00 960 $31.50 $22.50 $36.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334279 PHYSICIAN FEE - SURGERY PF-ENDOSCOPY BOWEL POUCH/BIOP EACH 44386 $236.00 960 $165.20 $118.00 $188.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329154 PHYSICIAN FEE - SURGERY PF-ENDOSCOPY LIGATE PERF VEINS EACH 37500 "$1,776.00 " 960 "$1,243.20 " $888.00 "$1,420.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320617 PHYSICIAN FEE - SURGERY PF-ENDOSCOPY MAXILLARY SINUS EACH 31267 $714.00 960 $499.80 $357.00 $571.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334261 PHYSICIAN FEE - SURGERY PF-ENDOSCOPY OF BOWEL POUCH EACH 44385 $194.00 960 $135.80 $97.00 $155.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339344 PHYSICIAN FEE - SURGERY PF-ENDOSCOPY OF URETER EACH 50951 $809.00 960 $566.30 $404.50 $647.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339351 PHYSICIAN FEE - SURGERY PF-ENDOSCOPY OF URETER EACH 50953 $859.00 960 $601.30 $429.50 $687.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361157 PHYSICIAN FEE - SURGERY PF-ENDOSCOPY TRANSNASAL BX EACH 0653T "$1,063.00 " 960 $744.10 $531.50 $850.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325079 PHYSICIAN FEE - SURGERY PF-ENDOVASC PROSTH DELAYED EACH 33886 "$2,690.00 " 960 "$1,883.00 " "$1,345.00 " "$2,152.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325061 PHYSICIAN FEE - SURGERY PF-ENDOVASC PROSTH TAA ADD-ON EACH 33884 "$1,121.00 " 960 $784.70 $560.50 $896.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325038 PHYSICIAN FEE - SURGERY PF-ENDOVASC TAA REPR INC SUBCL EACH 33880 "$5,011.00 " 960 "$3,507.70 " "$2,505.50 " "$4,008.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325046 PHYSICIAN FEE - SURGERY PF-ENDOVASC TAA REPR W/O SUBCL EACH 33881 "$4,303.00 " 960 "$3,012.10 " "$2,151.50 " "$3,442.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356975 PHYSICIAN FEE - SURGERY PF-ENDOVASC VISC AORTA 2 GRAFT EACH 34842 "$4,610.00 " 960 "$3,227.00 " "$2,305.00 " "$3,688.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356983 PHYSICIAN FEE - SURGERY PF-ENDOVASC VISC AORTA 3 GRAFT EACH 34843 "$5,558.00 " 960 "$3,890.60 " "$2,779.00 " "$4,446.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356991 PHYSICIAN FEE - SURGERY PF-ENDOVASC VISC AORTA 4 GRAFT EACH 34844 "$6,507.00 " 960 "$4,554.90 " "$3,253.50 " "$5,205.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359607 PHYSICIAN FEE - SURGERY PF-ENDOVEN MCHNCHEM 1ST VEIN EACH 36473 $502.00 960 $351.40 $251.00 $401.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359615 PHYSICIAN FEE - SURGERY PF-ENDOVENOUS MCHNCHEM ADD-ON EACH 36474 $244.00 960 $170.80 $122.00 $195.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303720 PHYSICIAN FEE - SURGERY PF-ENLARGE BREAST WITH IMPLANT EACH 19325 "$1,667.00 " 960 "$1,166.90 " $833.50 "$1,333.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333677 PHYSICIAN FEE - SURGERY PF-ENTERECTOMY CONG ADD-ON EACH 44128 $694.00 960 $485.80 $347.00 $555.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333651 PHYSICIAN FEE - SURGERY PF-ENTERECTOMY W/O TAPER CONG EACH 44126 "$7,017.00 " 960 "$4,911.90 " "$3,508.50 " "$5,613.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333669 PHYSICIAN FEE - SURGERY PF-ENTERECTOMY W/TAPER CONG EACH 44127 "$8,112.00 " 960 "$5,678.40 " "$4,056.00 " "$6,489.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352966 PHYSICIAN FEE - SURGERY PF-ENTROPION REP EXC TARSAL W EACH 67923 "$1,100.00 " 960 $770.00 $550.00 $880.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301906 PHYSICIAN FEE - SURGERY PF-EPIDRM A-GRFT F/N/HF/G ADDL EACH 15116 $386.00 960 $270.20 $193.00 $308.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301898 PHYSICIAN FEE - SURGERY PF-EPIDRM A-GRFT FACE/NCK/HF/G EACH 15115 "$1,878.00 " 960 "$1,314.60 " $939.00 "$1,502.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301880 PHYSICIAN FEE - SURGERY PF-EPIDRM AUTOGRT T/A/L ADD-ON EACH 15111 $285.00 960 $199.50 $142.50 $228.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301872 PHYSICIAN FEE - SURGERY PF-EPIDRM AUTOGRT TRNK/ARM/LEG EACH 15110 "$1,956.00 " 960 "$1,369.20 " $978.00 "$1,564.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347701 PHYSICIAN FEE - SURGERY PF-EPIDURL LYSIS MULT SESSIONS EACH 62263 $849.00 960 $594.30 $424.50 $679.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347719 PHYSICIAN FEE - SURGERY PF-EPIDURL LYSIS ON SINGLE DAY EACH 62264 $641.00 960 $448.70 $320.50 $512.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345093 PHYSICIAN FEE - SURGERY PF-EPISIOTOMY OR VAGINAL REP EACH 59300 $430.00 960 $301.00 $215.00 $344.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332422 PHYSICIAN FEE - SURGERY PF-ERCP DUCT STENT PLACEMENT EACH 43274 "$1,212.00 " 960 $848.40 $606.00 $969.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332455 PHYSICIAN FEE - SURGERY PF-ERCP EA DUCT/AMPULL DIALATE EACH 43277 $989.00 960 $692.30 $494.50 $791.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332463 PHYSICIAN FEE - SURGERY PF-ERCP LESION ABLATE W/DILATE EACH 43278 "$1,134.00 " 960 $793.80 $567.00 $907.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332430 PHYSICIAN FEE - SURGERY PF-ERCP REMOVE FORGN BODY DUCT EACH 43275 $985.00 960 $689.50 $492.50 $788.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332448 PHYSICIAN FEE - SURGERY PF-ERCP STENT EXCH W/DILATE EACH 43276 "$1,262.00 " 960 $883.40 $631.00 "$1,009.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302995 PHYSICIAN FEE - SURGERY PF-ESCHAROTOMY ADDL INCISION EACH 16036 $231.00 960 $161.70 $115.50 $184.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332075 PHYSICIAN FEE - SURGERY PF-ESOPH ENDOSCOPY DILATION EACH 43220 $313.00 960 $219.10 $156.50 $250.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332083 PHYSICIAN FEE - SURGERY PF-ESOPH ENDOSCOPY DILATION EACH 43226 $351.00 960 $245.70 $175.50 $280.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332265 PHYSICIAN FEE - SURGERY PF-ESOPH ENDOSCOPY DILATION EACH 43249 $405.00 960 $283.50 $202.50 $324.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332091 PHYSICIAN FEE - SURGERY PF-ESOPH ENDOSCOPY REPAIR EACH 43227 $436.00 960 $305.20 $218.00 $348.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332109 PHYSICIAN FEE - SURGERY PF-ESOPH ENDOSCOPY W/US EXAM EACH 43231 $411.00 960 $287.70 $205.50 $328.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332117 PHYSICIAN FEE - SURGERY PF-ESOPH ENDOSCOPY W/US FN BX EACH 43232 $521.00 960 $364.70 $260.50 $416.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332174 PHYSICIAN FEE - SURGERY PF-ESOPH ENDOSCPE W/DRAIN CYST EACH 43240 "$1,027.00 " 960 $718.90 $513.50 $821.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332604 PHYSICIAN FEE - SURGERY PF-ESOPH FUNDOPLASTY LAP EACH 43327 "$2,305.00 " 960 "$1,613.50 " "$1,152.50 " "$1,844.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332612 PHYSICIAN FEE - SURGERY PF-ESOPH FUNDOPLASTY THOR EACH 43328 "$3,157.00 " 960 "$2,209.90 " "$1,578.50 " "$2,525.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332703 PHYSICIAN FEE - SURGERY PF-ESOPH LENGTHENING EACH 43338 $323.00 960 $226.10 $161.50 $258.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355019 PHYSICIAN FEE - SURGERY PF-ESOPH OPTICAL ENDOMICROSCPY EACH 43206 $347.00 960 $242.90 $173.50 $277.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332000 PHYSICIAN FEE - SURGERY PF-ESOPH SCOPE W/SCLEROSIS INJ EACH 43204 $354.00 960 $247.80 $177.00 $283.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331986 PHYSICIAN FEE - SURGERY PF-ESOPH SCOPE W/SUBMUCOUS INJ EACH 43201 $276.00 960 $193.20 $138.00 $220.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331945 PHYSICIAN FEE - SURGERY PF-ESOPHAGGOS RIG TRNSO REM FB EACH 43194 $517.00 960 $361.90 $258.50 $413.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332620 PHYSICIAN FEE - SURGERY PF-ESOPHAGOMYOTOMY ABDOMINAL EACH 43330 "$3,795.00 " 960 "$2,656.50 " "$1,897.50 " "$3,036.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332638 PHYSICIAN FEE - SURGERY PF-ESOPHAGOMYOTOMY THORACIC EACH 43331 "$3,764.00 " 960 "$2,634.80 " "$1,882.00 " "$3,011.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332562 PHYSICIAN FEE - SURGERY PF-ESOPHAGOPLASTY CONGENITAL EACH 43313 "$8,235.00 " 960 "$5,764.50 " "$4,117.50 " "$6,588.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355001 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSC FLEX TRNSN BX EACH 43198 $262.00 960 $183.40 $131.00 $209.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332026 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSC STENT PLACEMENT EACH 43212 $508.00 960 $355.60 $254.00 $406.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355027 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSCOP MUCOSAL RESECT EACH 43211 $614.00 960 $429.80 $307.00 $491.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331960 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSCOPY FLEX DX BRUSH EACH 43197 $222.00 960 $155.40 $111.00 $177.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355043 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSCOPY LESION ABLATE EACH 43229 $518.00 960 $362.60 $259.00 $414.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332034 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSCOPY RETRO BALLOON EACH 43213 $698.00 960 $488.60 $349.00 $558.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354996 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSCOPY RIGID BALLOON EACH 43195 $497.00 960 $347.90 $248.50 $397.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354962 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSCOPY RIGID TRNSO EACH 43180 "$1,475.00 " 960 "$1,032.50 " $737.50 "$1,180.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331952 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSCP GD WIRE DILAT EACH 43196 $524.00 960 $366.80 $262.00 $419.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354988 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSCP RIG TRNSO BX EACH 43193 $455.00 960 $318.50 $227.50 $364.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354970 PHYSICIAN FEE - SURGERY PF-ESOPHAGOSCP RIG TRNSO INJ EACH 43192 $456.00 960 $319.20 $228.00 $364.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355035 PHYSICIAN FEE - SURGERY PF-ESOPHAGSC DILATE BALLOON 30 EACH 43214 $520.00 960 $364.00 $260.00 $416.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331978 PHYSICIAN FEE - SURGERY PF-ESOPHAGUS ENDOSCOPY EACH 43200 $236.00 960 $165.20 $118.00 $188.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332042 PHYSICIAN FEE - SURGERY PF-ESOPHAGUS ENDOSCOPY EACH 43215 $379.00 960 $265.30 $189.50 $303.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332067 PHYSICIAN FEE - SURGERY PF-ESOPHAGUS ENDOSCOPY EACH 43217 $420.00 960 $294.00 $210.00 $336.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331994 PHYSICIAN FEE - SURGERY PF-ESOPHAGUS ENDOSCOPY BIOPSY EACH 43202 $273.00 960 $191.10 $136.50 $218.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332059 PHYSICIAN FEE - SURGERY PF-ESOPHAGUS ENDOSCOPY/LESION EACH 43216 $350.00 960 $245.00 $175.00 $280.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332018 PHYSICIAN FEE - SURGERY PF-ESOPHAGUS ENDOSCPY/LIGATION EACH 43205 $370.00 960 $259.00 $185.00 $296.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359201 PHYSICIAN FEE - SURGERY PF-ESOPHAGUS MOTILITY STUDY EACH 91010 $163.00 960 $114.10 $81.50 $130.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327588 PHYSICIAN FEE - SURGERY PF-ESTABLISH ACCESS TO AORTA EACH 36160 $326.00 960 $228.20 $163.00 $260.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327554 PHYSICIAN FEE - SURGERY PF-ESTABLISH ACCESS TO ARTERY EACH 36140 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327539 PHYSICIAN FEE - SURGERY PF-ESTABLISH ACCESS TO ARTERY EACH 36100 $429.00 960 $300.30 $214.50 $343.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347578 PHYSICIAN FEE - SURGERY PF-ESTABLISH BRAIN CAVTY SHUNT EACH 62180 "$4,827.00 " 960 "$3,378.90 " "$2,413.50 " "$3,861.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347586 PHYSICIAN FEE - SURGERY PF-ESTABLISH BRAIN CAVTY SHUNT EACH 62190 "$2,787.00 " 960 "$1,950.90 " "$1,393.50 " "$2,229.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347594 PHYSICIAN FEE - SURGERY PF-ESTABLISH BRAIN CAVTY SHUNT EACH 62192 "$2,975.00 " 960 "$2,082.50 " "$1,487.50 " "$2,380.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347610 PHYSICIAN FEE - SURGERY PF-ESTABLISH BRAIN CAVTY SHUNT EACH 62200 "$4,150.00 " 960 "$2,905.00 " "$2,075.00 " "$3,320.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347636 PHYSICIAN FEE - SURGERY PF-ESTABLISH BRAIN CAVTY SHUNT EACH 62220 "$2,903.00 " 960 "$2,032.10 " "$1,451.50 " "$2,322.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345440 PHYSICIAN FEE - SURGERY PF-EVACUATE MOLE OF UTERUS EACH 59870 "$1,522.00 " 960 "$1,065.40 " $761.00 "$1,217.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360258 PHYSICIAN FEE - SURGERY PF-EVASC PRLNG ADMN RX AGNT + EACH 61651 $730.00 960 $511.00 $365.00 $584.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502462 PHYSICIAN FEE - SURGERY PF-EVASC ST RPR THR/AA ACRS BR EACH 33894 "$2,725.00 " 960 "$1,907.50 " "$1,362.50 " "$2,180.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502470 PHYSICIAN FEE - SURGERY PF-EVASC ST RPR THRC/AA X CRSG EACH 33895 "$2,169.00 " 960 "$1,518.30 " "$1,084.50 " "$1,735.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308653 PHYSICIAN FEE - SURGERY PF-EX ARM/ELBOW TUM DEEP < 5 EACH 24076 "$1,511.00 " 960 "$1,057.70 " $755.50 "$1,208.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308638 PHYSICIAN FEE - SURGERY PF-EX ARM/ELBOW TUM DEEP > 5 EACH 24073 "$1,927.00 " 960 "$1,348.90 " $963.50 "$1,541.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343585 PHYSICIAN FEE - SURGERY PF-EXAM OF CERVIX W/SCOPE EACH 57452 $247.00 960 $172.90 $123.50 $197.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343536 PHYSICIAN FEE - SURGERY PF-EXAM OF VAGINA W/SCOPE EACH 57420 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342926 PHYSICIAN FEE - SURGERY PF-EXAM OF VULVA W/SCOPE EACH 56820 $229.00 960 $160.30 $114.50 $183.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343544 PHYSICIAN FEE - SURGERY PF-EXAM/BIOPSY OF VAG W/SCOPE EACH 57421 $334.00 960 $233.80 $167.00 $267.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342934 PHYSICIAN FEE - SURGERY PF-EXAM/BIOPSY VULVA W/SCOPE EACH 56821 $311.00 960 $217.70 $155.50 $248.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307507 PHYSICIAN FEE - SURGERY PF-EXC ABD LES SC < 3 CM EACH 22902 $932.00 960 $652.40 $466.00 $745.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307515 PHYSICIAN FEE - SURGERY PF-EXC ABD LES SC > 3 CM EACH 22903 "$1,237.00 " 960 $865.90 $618.50 $989.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337249 PHYSICIAN FEE - SURGERY PF-EXC ABD TUM 5 CM OR LESS EACH 49203 "$3,339.00 " 960 "$2,337.30 " "$1,669.50 " "$2,671.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337264 PHYSICIAN FEE - SURGERY PF-EXC ABD TUM OVER 10 CM EACH 49205 "$4,892.00 " 960 "$3,424.40 " "$2,446.00 " "$3,913.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337256 PHYSICIAN FEE - SURGERY PF-EXC ABD TUM OVER 5 CM EACH 49204 "$4,258.00 " 960 "$2,980.60 " "$2,129.00 " "$3,406.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308646 PHYSICIAN FEE - SURGERY PF-EXC ARM/ELBOW LES SC < 3 CM EACH 24075 $910.00 960 $637.00 $455.00 $728.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308620 PHYSICIAN FEE - SURGERY PF-EXC ARM/ELBOW LES SC 3+ CM EACH 24071 "$1,130.00 " 960 $791.00 $565.00 $904.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306616 PHYSICIAN FEE - SURGERY PF-EXC BACK LES SC < 3 CM EACH 21930 "$1,012.00 " 960 $708.40 $506.00 $809.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306624 PHYSICIAN FEE - SURGERY PF-EXC BACK LES SC 3+ CM EACH 21931 "$1,318.00 " 960 $922.60 $659.00 "$1,054.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306632 PHYSICIAN FEE - SURGERY PF-EXC BACK TUM DEEP < 5 CM EACH 21932 "$1,847.00 " 960 "$1,292.90 " $923.50 "$1,477.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307481 PHYSICIAN FEE - SURGERY PF-EXC BACK TUM DEEP < 5 CM EACH 22900 "$1,585.00 " 960 "$1,109.50 " $792.50 "$1,268.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306640 PHYSICIAN FEE - SURGERY PF-EXC BACK TUM DEEP 5+ CM EACH 21933 "$2,066.00 " 960 "$1,446.20 " "$1,033.00 " "$1,652.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307499 PHYSICIAN FEE - SURGERY PF-EXC BACK TUM DEEP 5+ CM EACH 22901 "$1,871.00 " 960 "$1,309.70 " $935.50 "$1,496.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352685 PHYSICIAN FEE - SURGERY PF-EXC CHALAZION MULT DIFF LID EACH 67805 $418.00 960 $292.60 $209.00 $334.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352677 PHYSICIAN FEE - SURGERY PF-EXC CHALAZION MULT SAME LID EACH 67801 $337.00 960 $235.90 $168.50 $269.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304728 PHYSICIAN FEE - SURGERY PF-EXC FACE LES SBQ 2+ CM EACH 21012 $930.00 960 $651.00 $465.00 $744.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304710 PHYSICIAN FEE - SURGERY PF-EXC FACE LES SC < 2 CM EACH 21011 $701.00 960 $490.70 $350.50 $560.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304736 PHYSICIAN FEE - SURGERY PF-EXC FACE TUM DEEP < 2 CM EACH 21013 "$1,091.00 " 960 $763.70 $545.50 $872.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304744 PHYSICIAN FEE - SURGERY PF-EXC FACE TUM DEEP 2+ CM EACH 21014 "$1,423.00 " 960 $996.10 $711.50 "$1,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300601 PHYSICIAN FEE - SURGERY PF-EXC FACE-MM B9+MARG 0.6-1 EACH 11441 $352.00 960 $246.40 $176.00 $281.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300619 PHYSICIAN FEE - SURGERY PF-EXC FACE-MM B9+MARG 1.1-2 EACH 11442 $390.00 960 $273.00 $195.00 $312.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300627 PHYSICIAN FEE - SURGERY PF-EXC FACE-MM B9+MARG 2.1-3 EACH 11443 $476.00 960 $333.20 $238.00 $380.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300833 PHYSICIAN FEE - SURGERY PF-EXC FACE-MM MALIG+MRG 0.5 < EACH 11640 $334.00 960 $233.80 $167.00 $267.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300841 PHYSICIAN FEE - SURGERY PF-EXC FACE-MM MALIG+MRG 0.6-1 EACH 11641 $410.00 960 $287.00 $205.00 $328.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300866 PHYSICIAN FEE - SURGERY PF-EXC FACE-MM MALIG+MRG 2.1-3 EACH 11643 $602.00 960 $421.40 $301.00 $481.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300874 PHYSICIAN FEE - SURGERY PF-EXC FACE-MM MALIG+MRG 3.1-4 EACH 11644 $750.00 960 $525.00 $375.00 $600.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300882 PHYSICIAN FEE - SURGERY PF-EXC FACE-MM MLG+MARG > 4 CM EACH 11646 "$1,045.00 " 960 $731.50 $522.50 $836.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316946 PHYSICIAN FEE - SURGERY PF-EXC FOOT/TOE TUM DEEP <1.5 EACH 28045 $915.00 960 $640.50 $457.50 $732.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316938 PHYSICIAN FEE - SURGERY PF-EXC FOOT/TOE TUM SC < 1.5 EACH 28043 $689.00 960 $482.30 $344.50 $551.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316912 PHYSICIAN FEE - SURGERY PF-EXC FOOT/TOE TUM SC > 1.5 EACH 28039 $900.00 960 $630.00 $450.00 $720.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309834 PHYSICIAN FEE - SURGERY PF-EXC FOREARM LES SC < 3 CM EACH 25075 $868.00 960 $607.60 $434.00 $694.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309818 PHYSICIAN FEE - SURGERY PF-EXC FOREARM LES SC > 3 CM EACH 25071 "$1,177.00 " 960 $823.90 $588.50 $941.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309842 PHYSICIAN FEE - SURGERY PF-EXC FOREARM TUM DEEP < 3 CM EACH 25076 "$1,425.00 " 960 $997.50 $712.50 "$1,140.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309826 PHYSICIAN FEE - SURGERY PF-EXC FOREARM TUM DEEP 3+ CM EACH 25073 "$1,478.00 " 960 "$1,034.60 " $739.00 "$1,182.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311467 PHYSICIAN FEE - SURGERY PF-EXC HAND LES SC < 1.5 CM EACH 26115 $911.00 960 $637.70 $455.50 $728.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311442 PHYSICIAN FEE - SURGERY PF-EXC HAND LES SC > 1.5 CM EACH 26111 "$1,143.00 " 960 $800.10 $571.50 $914.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311475 PHYSICIAN FEE - SURGERY PF-EXC HAND TUM DEEP < 1.5 CM EACH 26116 "$1,438.00 " 960 "$1,006.60 " $719.00 "$1,150.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311459 PHYSICIAN FEE - SURGERY PF-EXC HAND TUM DEEP > 1.5 CM EACH 26113 "$1,500.00 " 960 "$1,050.00 " $750.00 "$1,200.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311483 PHYSICIAN FEE - SURGERY PF-EXC HAND TUM RA < 3 CM EACH 26117 "$2,038.00 " 960 "$1,426.60 " "$1,019.00 " "$1,630.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311491 PHYSICIAN FEE - SURGERY PF-EXC HAND TUM RA > 3 CM EACH 26118 "$2,877.00 " 960 "$2,013.90 " "$1,438.50 " "$2,301.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300536 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP B9+MARG 0.5 < EACH 11420 $215.00 960 $150.50 $107.50 $172.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300544 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP B9+MARG 0.6-1 EACH 11421 $288.00 960 $201.60 $144.00 $230.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300551 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP B9+MARG 1.1-2 EACH 11422 $359.00 960 $251.30 $179.50 $287.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300569 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP B9+MARG 2.1-3 EACH 11423 $417.00 960 $291.90 $208.50 $333.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300577 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP B9+MARG 3.1-4 EACH 11424 $485.00 960 $339.50 $242.50 $388.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300825 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP MLG+MAR > 4 EACH 11626 $785.00 960 $549.50 $392.50 $628.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300775 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP MLG+MRG 0.5 < EACH 11620 $328.00 960 $229.60 $164.00 $262.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300783 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP MLG+MRG 0.6-1 EACH 11621 $393.00 960 $275.10 $196.50 $314.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300791 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP MLG+MRG 1.1-2 EACH 11622 $446.00 960 $312.20 $223.00 $356.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300809 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP MLG+MRG 2.1-3 EACH 11623 $552.00 960 $386.40 $276.00 $441.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300817 PHYSICIAN FEE - SURGERY PF-EXC H-F-NK-SP MLG+MRG 3.1-4 EACH 11624 $634.00 960 $443.80 $317.00 $507.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313208 PHYSICIAN FEE - SURGERY PF-EXC HIP PELVIS LES SC > 3 EACH 27043 "$1,318.00 " 960 $922.60 $659.00 "$1,054.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313232 PHYSICIAN FEE - SURGERY PF-EXC HIP/PELV TUM DEEP < 5 EACH 27048 "$1,380.00 " 960 $966.00 $690.00 "$1,104.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313216 PHYSICIAN FEE - SURGERY PF-EXC HIP/PELV TUM DEEP > 5 EACH 27045 "$2,036.00 " 960 "$1,425.20 " "$1,018.00 " "$1,628.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313224 PHYSICIAN FEE - SURGERY PF-EXC HIP/PELVIS LES SC < 3 EACH 27047 "$1,007.00 " 960 $704.90 $503.50 $805.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502421 PHYSICIAN FEE - SURGERY PF-EXC LAA OPN OTH PX ANY METH EACH 33268 $363.00 960 $254.10 $181.50 $290.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315773 PHYSICIAN FEE - SURGERY PF-EXC LEG/ANKLE LES SC 3+ CM EACH 27632 "$1,131.00 " 960 $791.70 $565.50 $904.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315716 PHYSICIAN FEE - SURGERY PF-EXC LEG/ANKLE TUM < 3 CM EACH 27618 $838.00 960 $586.60 $419.00 $670.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315724 PHYSICIAN FEE - SURGERY PF-EXC LEG/ANKLE TUM DEEP <5 EACH 27619 "$1,285.00 " 960 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315781 PHYSICIAN FEE - SURGERY PF-EXC LEG/ANKLE TUM DEEP 5+ EACH 27634 "$1,852.00 " 960 "$1,296.40 " $926.00 "$1,481.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352750 PHYSICIAN FEE - SURGERY PF-EXC LESN EYELID NOT CHALAZ EACH 67840 $403.00 960 $282.10 $201.50 $322.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306368 PHYSICIAN FEE - SURGERY PF-EXC NECK LES SC < 3 CM EACH 21555 $843.00 960 $590.10 $421.50 $674.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306343 PHYSICIAN FEE - SURGERY PF-EXC NECK LES SC 3+ CM EACH 21552 "$1,251.00 " 960 $875.70 $625.50 "$1,000.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306376 PHYSICIAN FEE - SURGERY PF-EXC NECK TUM DEEP < 5 CM EACH 21556 "$1,456.00 " 960 "$1,019.20 " $728.00 "$1,164.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306350 PHYSICIAN FEE - SURGERY PF-EXC NECK TUM DEEP 5+ CM EACH 21554 "$2,031.00 " 960 "$1,421.70 " "$1,015.50 " "$1,624.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334824 PHYSICIAN FEE - SURGERY PF-EXC RECT TUM TRANSANAL FULL EACH 45172 "$2,232.00 " 960 "$1,562.40 " "$1,116.00 " "$1,785.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334816 PHYSICIAN FEE - SURGERY PF-EXC RECT TUM TRANSANAL PART EACH 45171 "$1,674.00 " 960 "$1,171.80 " $837.00 "$1,339.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357130 PHYSICIAN FEE - SURGERY PF-EXC RECTAL TUMOR ENDOSCOPIC EACH 0184T "$2,306.00 " 960 "$1,614.20 " "$1,153.00 " "$1,844.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307655 PHYSICIAN FEE - SURGERY PF-EXC SHOULDER LES SC < 3 CM EACH 23075 $910.00 960 $637.00 $455.00 $728.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307630 PHYSICIAN FEE - SURGERY PF-EXC SHOULDER LES SC > 3 CM EACH 23071 "$1,174.00 " 960 $821.80 $587.00 $939.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307663 PHYSICIAN FEE - SURGERY PF-EXC SHOULDER TUM DEEP < 5 EACH 23076 "$1,507.00 " 960 "$1,054.90 " $753.50 "$1,205.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307648 PHYSICIAN FEE - SURGERY PF-EXC SHOULDER TUM DEEP > 5 EACH 23073 "$1,939.00 " 960 "$1,357.30 " $969.50 "$1,551.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302581 PHYSICIAN FEE - SURGERY PF-EXC SKIN ABD EACH 15830 "$3,200.00 " 960 "$2,240.00 " "$1,600.00 " "$2,560.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302714 PHYSICIAN FEE - SURGERY PF-EXC SKIN ABD ADD-ON EACH 15847 $830.00 960 $581.00 $415.00 $664.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314339 PHYSICIAN FEE - SURGERY PF-EXC THIGH/KNEE LES SC < 3 EACH 27327 $872.00 960 $610.40 $436.00 $697.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314420 PHYSICIAN FEE - SURGERY PF-EXC THIGH/KNEE LES SC 3+ CM EACH 27337 "$1,172.00 " 960 $820.40 $586.00 $937.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314347 PHYSICIAN FEE - SURGERY PF-EXC THIGH/KNEE TUM DEEP <5 EACH 27328 "$1,736.00 " 960 "$1,215.20 " $868.00 "$1,388.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314438 PHYSICIAN FEE - SURGERY PF-EXC THIGH/KNEE TUM DEEP 5+ EACH 27339 "$2,106.00 " 960 "$1,474.20 " "$1,053.00 " "$1,684.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300528 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT B9+MARG > 4.0 CM EACH 11406 $677.00 960 $473.90 $338.50 $541.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300478 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT B9+MARG 0.5 < CM EACH 11400 $223.00 960 $156.10 $111.50 $178.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300486 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT B9+MARG 0.6-1 CM EACH 11401 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300494 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT B9+MARG 1.1-2 CM EACH 11402 $306.00 960 $214.20 $153.00 $244.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300502 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT B9+MARG 2.1-3 CM EACH 11403 $399.00 960 $279.30 $199.50 $319.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300510 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT B9+MARG 3.1-4 CM EACH 11404 $442.00 960 $309.40 $221.00 $353.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300767 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT MLG+MARG > 4 CM EACH 11606 $857.00 960 $599.90 $428.50 $685.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300718 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT MLG+MARG 0.5 < EACH 11600 $324.00 960 $226.80 $162.00 $259.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300726 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT MLG+MARG 0.6-1 EACH 11601 $391.00 960 $273.70 $195.50 $312.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300734 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT MLG+MARG 1.1-2 EACH 11602 $422.00 960 $295.40 $211.00 $337.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300742 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT MLG+MARG 2.1-3 EACH 11603 $508.00 960 $355.60 $254.00 $406.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300759 PHYSICIAN FEE - SURGERY PF-EXC TR-EXT MLG+MARG 3.1-4 EACH 11604 $562.00 960 $393.40 $281.00 $449.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351125 PHYSICIAN FEE - SURGERY PF-EXC/TRANSPOS PTERYGIUM W/GR EACH 65426 "$1,223.00 " 960 $856.10 $611.50 $978.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351935 PHYSICIAN FEE - SURGERY PF-EXCHANGE LENS PROSTHESIS EACH 66986 "$2,304.00 " 960 "$1,612.80 " "$1,152.00 " "$1,843.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304900 PHYSICIAN FEE - SURGERY PF-EXCIS UPPR JAW CYST W/REP EACH 21049 "$3,042.00 " 960 "$2,129.40 " "$1,521.00 " "$2,433.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335482 PHYSICIAN FEE - SURGERY PF-EXCISE ANAL EXT TAG/PAPILLA EACH 46220 $331.00 960 $231.70 $165.50 $264.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303472 PHYSICIAN FEE - SURGERY PF-EXCISE BREAST DUCT FISTULA EACH 19112 $898.00 960 $628.60 $449.00 $718.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312564 PHYSICIAN FEE - SURGERY PF-EXCISE CONSTRICTING TISSUE EACH 26596 "$2,224.00 " 960 "$1,556.80 " "$1,112.00 " "$1,779.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303951 PHYSICIAN FEE - SURGERY PF-EXCISE EPIPHYSEAL BAR EACH 20150 "$2,765.00 " 960 "$1,935.50 " "$1,382.50 " "$2,212.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302599 PHYSICIAN FEE - SURGERY PF-EXCISE EXCESS SKIN TISSUE EACH 15832 "$2,505.00 " 960 "$1,753.50 " "$1,252.50 " "$2,004.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302607 PHYSICIAN FEE - SURGERY PF-EXCISE EXCESS SKIN TISSUE EACH 15833 "$2,374.00 " 960 "$1,661.80 " "$1,187.00 " "$1,899.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302615 PHYSICIAN FEE - SURGERY PF-EXCISE EXCESS SKIN TISSUE EACH 15834 "$2,416.00 " 960 "$1,691.20 " "$1,208.00 " "$1,932.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302623 PHYSICIAN FEE - SURGERY PF-EXCISE EXCESS SKIN TISSUE EACH 15835 "$2,522.00 " 960 "$1,765.40 " "$1,261.00 " "$2,017.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302631 PHYSICIAN FEE - SURGERY PF-EXCISE EXCESS SKIN TISSUE EACH 15836 "$2,156.00 " 960 "$1,509.20 " "$1,078.00 " "$1,724.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302649 PHYSICIAN FEE - SURGERY PF-EXCISE EXCESS SKIN TISSUE EACH 15837 "$1,937.00 " 960 "$1,355.90 " $968.50 "$1,549.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302656 PHYSICIAN FEE - SURGERY PF-EXCISE EXCESS SKIN TISSUE EACH 15838 "$1,753.00 " 960 "$1,227.10 " $876.50 "$1,402.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302664 PHYSICIAN FEE - SURGERY PF-EXCISE EXCESS SKIN TISSUE EACH 15839 "$2,008.00 " 960 "$1,405.60 " "$1,004.00 " "$1,606.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317076 PHYSICIAN FEE - SURGERY PF-EXCISE FOOT TEND SHEATH EXT EACH 28088 $782.00 960 $547.40 $391.00 $625.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317068 PHYSICIAN FEE - SURGERY PF-EXCISE FOOT TENDON SH FLEX EACH 28086 $936.00 960 $655.20 $468.00 $748.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334782 PHYSICIAN FEE - SURGERY PF-EXCISE ILEOANAL RESERVIOR EACH 45136 "$4,741.00 " 960 "$3,318.70 " "$2,370.50 " "$3,792.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319932 PHYSICIAN FEE - SURGERY PF-EXCISE INFERIOR TURBINATE EACH 30130 "$1,091.00 " 960 $763.70 $545.50 $872.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333602 PHYSICIAN FEE - SURGERY PF-EXCISE INTESTINE LESION(S) EACH 44110 "$2,368.00 " 960 "$1,657.60 " "$1,184.00 " "$1,894.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348642 PHYSICIAN FEE - SURGERY PF-EXCISE INTRASPINAL LESION EACH 63265 "$4,974.00 " 960 "$3,481.80 " "$2,487.00 " "$3,979.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348659 PHYSICIAN FEE - SURGERY PF-EXCISE INTRASPINAL LESION EACH 63266 "$5,098.00 " 960 "$3,568.60 " "$2,549.00 " "$4,078.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348667 PHYSICIAN FEE - SURGERY PF-EXCISE INTRASPINAL LESION EACH 63267 "$4,022.00 " 960 "$2,815.40 " "$2,011.00 " "$3,217.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348675 PHYSICIAN FEE - SURGERY PF-EXCISE INTRASPINAL LESION EACH 63268 "$4,399.00 " 960 "$3,079.30 " "$2,199.50 " "$3,519.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348683 PHYSICIAN FEE - SURGERY PF-EXCISE INTRASPINAL LESION EACH 63270 "$6,274.00 " 960 "$4,391.80 " "$3,137.00 " "$5,019.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348691 PHYSICIAN FEE - SURGERY PF-EXCISE INTRASPINAL LESION EACH 63271 "$6,241.00 " 960 "$4,368.70 " "$3,120.50 " "$4,992.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348709 PHYSICIAN FEE - SURGERY PF-EXCISE INTRASPINAL LESION EACH 63272 "$5,533.00 " 960 "$3,873.10 " "$2,766.50 " "$4,426.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348717 PHYSICIAN FEE - SURGERY PF-EXCISE INTRASPINAL LESION EACH 63273 "$5,638.00 " 960 "$3,946.60 " "$2,819.00 " "$4,510.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341969 PHYSICIAN FEE - SURGERY PF-EXCISE LESION TESTIS EACH 54512 "$1,435.00 " 960 "$1,004.50 " $717.50 "$1,148.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330301 PHYSICIAN FEE - SURGERY PF-EXCISE LIP OR CHEEK FOLD EACH 40819 $520.00 960 $364.00 $260.00 $416.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304884 PHYSICIAN FEE - SURGERY PF-EXCISE LWR JAW CYST W/REP EACH 21047 "$3,196.00 " 960 "$2,237.20 " "$1,598.00 " "$2,556.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304843 PHYSICIAN FEE - SURGERY PF-EXCISE MANDIBLE LESION EACH 21040 $944.00 960 $660.80 $472.00 $755.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304801 PHYSICIAN FEE - SURGERY PF-EXCISE MAX/ZYGOMA B9 TUMOR EACH 21030 $941.00 960 $658.70 $470.50 $752.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304835 PHYSICIAN FEE - SURGERY PF-EXCISE MAX/ZYGOMA MLG TUMOR EACH 21034 "$3,005.00 " 960 "$2,103.50 " "$1,502.50 " "$2,404.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330293 PHYSICIAN FEE - SURGERY PF-EXCISE ORAL MUCOSA FOR GRFT EACH 40818 $694.00 960 $485.80 $347.00 $555.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331226 PHYSICIAN FEE - SURGERY PF-EXCISE PAROTID GLAND/LESION EACH 42410 "$1,707.00 " 960 "$1,194.90 " $853.50 "$1,365.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331234 PHYSICIAN FEE - SURGERY PF-EXCISE PAROTID GLAND/LESION EACH 42415 "$2,859.00 " 960 "$2,001.30 " "$1,429.50 " "$2,287.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331242 PHYSICIAN FEE - SURGERY PF-EXCISE PAROTID GLAND/LESION EACH 42420 "$3,197.00 " 960 "$2,237.90 " "$1,598.50 " "$2,557.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331259 PHYSICIAN FEE - SURGERY PF-EXCISE PAROTID GLAND/LESION EACH 42425 "$2,268.00 " 960 "$1,587.60 " "$1,134.00 " "$1,814.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331267 PHYSICIAN FEE - SURGERY PF-EXCISE PAROTID GLAND/LESION EACH 42426 "$3,648.00 " 960 "$2,553.60 " "$1,824.00 " "$2,918.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331457 PHYSICIAN FEE - SURGERY PF-EXCISE PHARYNX LESION EACH 42808 $446.00 960 $312.20 $223.00 $356.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337272 PHYSICIAN FEE - SURGERY PF-EXCISE SACRAL SPINE TUMOR EACH 49215 "$6,189.00 " 960 "$4,332.30 " "$3,094.50 " "$4,951.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331283 PHYSICIAN FEE - SURGERY PF-EXCISE SUBLINGUAL GLAND EACH 42450 $977.00 960 $683.90 $488.50 $781.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331275 PHYSICIAN FEE - SURGERY PF-EXCISE SUBMAXILLARY GLAND EACH 42440 "$1,123.00 " 960 $786.10 $561.50 $898.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309925 PHYSICIAN FEE - SURGERY PF-EXCISE TENDON FOREARM/WRIST EACH 25109 "$1,472.00 " 960 "$1,030.40 " $736.00 "$1,177.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309982 PHYSICIAN FEE - SURGERY PF-EXCISE WRIST TENDON SHEATH EACH 25118 "$1,052.00 " 960 $736.40 $526.00 $841.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330269 PHYSICIAN FEE - SURGERY PF-EXCISE/REPAIR MOUTH LESION EACH 40812 $477.00 960 $333.90 $238.50 $381.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330277 PHYSICIAN FEE - SURGERY PF-EXCISE/REPAIR MOUTH LESION EACH 40814 $742.00 960 $519.40 $371.00 $593.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303506 PHYSICIAN FEE - SURGERY PF-EXCISION ADDL BREAST LESION EACH 19126 $456.00 960 $319.20 $228.00 $364.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303498 PHYSICIAN FEE - SURGERY PF-EXCISION BREAST LESION EACH 19125 "$1,302.00 " 960 $911.40 $651.00 "$1,041.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331788 PHYSICIAN FEE - SURGERY PF-EXCISION ESOPHAGUS LESION EACH 43100 "$1,716.00 " 960 "$1,201.20 " $858.00 "$1,372.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331796 PHYSICIAN FEE - SURGERY PF-EXCISION ESOPHAGUS LESION EACH 43101 "$2,826.00 " 960 "$1,978.20 " "$1,413.00 " "$2,260.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327448 PHYSICIAN FEE - SURGERY PF-EXCISION GRAFT ABDOMEN EACH 35907 "$5,388.00 " 960 "$3,771.60 " "$2,694.00 " "$4,310.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327422 PHYSICIAN FEE - SURGERY PF-EXCISION GRAFT EXTREMITY EACH 35903 "$1,574.00 " 960 "$1,101.80 " $787.00 "$1,259.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327414 PHYSICIAN FEE - SURGERY PF-EXCISION GRAFT NECK EACH 35901 "$1,337.00 " 960 $935.90 $668.50 "$1,069.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327430 PHYSICIAN FEE - SURGERY PF-EXCISION GRAFT THORAX EACH 35905 "$4,756.00 " 960 "$3,329.20 " "$2,378.00 " "$3,804.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358567 PHYSICIAN FEE - SURGERY PF-EXCISION GUM EACH QUADRANT EACH 34706 "$6,401.00 " 960 "$4,480.70 " "$3,200.50 " "$5,120.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311863 PHYSICIAN FEE - SURGERY PF-EXCISION HAND/FINGER TENDON EACH 26415 "$2,295.00 " 960 "$1,606.50 " "$1,147.50 " "$1,836.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313174 PHYSICIAN FEE - SURGERY PF-EXCISION HIP JOINT/MUSCLE EACH 27036 "$2,802.00 " 960 "$1,961.40 " "$1,401.00 " "$2,241.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353121 PHYSICIAN FEE - SURGERY PF-EXCISION LESION CONJ >1 CM EACH 68115 $468.00 960 $327.60 $234.00 $374.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330905 PHYSICIAN FEE - SURGERY PF-EXCISION LESION MOUTH ROOF EACH 42104 $359.00 960 $251.30 $179.50 $287.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330913 PHYSICIAN FEE - SURGERY PF-EXCISION LESION MOUTH ROOF EACH 42106 $422.00 960 $295.40 $211.00 $337.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330921 PHYSICIAN FEE - SURGERY PF-EXCISION LESION MOUTH ROOF EACH 42107 $852.00 960 $596.40 $426.00 $681.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334535 PHYSICIAN FEE - SURGERY PF-EXCISION MESENTERY LESION EACH 44820 "$2,418.00 " 960 "$1,692.60 " "$1,209.00 " "$1,934.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336019 PHYSICIAN FEE - SURGERY PF-EXCISION OF ANAL LESION(S) EACH 46922 $377.00 960 $263.90 $188.50 $301.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336720 PHYSICIAN FEE - SURGERY PF-EXCISION OF BILE DUCT CYST EACH 47715 "$3,771.00 " 960 "$2,639.70 " "$1,885.50 " "$3,016.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336704 PHYSICIAN FEE - SURGERY PF-EXCISION OF BILE DUCT TUMOR EACH 47711 "$4,404.00 " 960 "$3,082.80 " "$2,202.00 " "$3,523.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336712 PHYSICIAN FEE - SURGERY PF-EXCISION OF BILE DUCT TUMOR EACH 47712 "$5,666.00 " 960 "$3,966.20 " "$2,833.00 " "$4,532.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304777 PHYSICIAN FEE - SURGERY PF-EXCISION OF BONE LOWER JAW EACH 21025 "$1,742.00 " 960 "$1,219.40 " $871.00 "$1,393.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333610 PHYSICIAN FEE - SURGERY PF-EXCISION OF BOWEL LESION(S) EACH 44111 "$2,727.00 " 960 "$1,908.90 " "$1,363.50 " "$2,181.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334527 PHYSICIAN FEE - SURGERY PF-EXCISION OF BOWEL POUCH EACH 44800 "$2,182.00 " 960 "$1,527.40 " "$1,091.00 " "$1,745.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346422 PHYSICIAN FEE - SURGERY PF-EXCISION OF BRAIN TUMOR EACH 61545 "$9,622.00 " 960 "$6,735.40 " "$4,811.00 " "$7,697.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304785 PHYSICIAN FEE - SURGERY PF-EXCISION OF FACIAL BONE(S) EACH 21026 "$1,122.00 " 960 $785.40 $561.00 $897.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330798 PHYSICIAN FEE - SURGERY PF-EXCISION OF GUM LESION EACH 41822 $542.00 960 $379.40 $271.00 $433.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330806 PHYSICIAN FEE - SURGERY PF-EXCISION OF GUM LESION EACH 41823 $984.00 960 $688.80 $492.00 $787.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330814 PHYSICIAN FEE - SURGERY PF-EXCISION OF GUM LESION EACH 41825 $319.00 960 $223.30 $159.50 $255.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330822 PHYSICIAN FEE - SURGERY PF-EXCISION OF GUM LESION EACH 41826 $508.00 960 $355.60 $254.00 $406.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330830 PHYSICIAN FEE - SURGERY PF-EXCISION OF GUM LESION EACH 41827 $757.00 960 $529.90 $378.50 $605.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330848 PHYSICIAN FEE - SURGERY PF-EXCISION OF GUM LESION EACH 41828 $602.00 960 $421.40 $301.00 $481.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331614 PHYSICIAN FEE - SURGERY PF-EXCISION OF LINGUAL TONSIL EACH 42870 "$1,543.00 " 960 "$1,080.10 " $771.50 "$1,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330251 PHYSICIAN FEE - SURGERY PF-EXCISION OF MOUTH LESION EACH 40810 $322.00 960 $225.40 $161.00 $257.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330285 PHYSICIAN FEE - SURGERY PF-EXCISION OF MOUTH LESION EACH 40816 $802.00 960 $561.40 $401.00 $641.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330590 PHYSICIAN FEE - SURGERY PF-EXCISION OF MOUTH LESION EACH 41116 $573.00 960 $401.10 $286.50 $458.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331473 PHYSICIAN FEE - SURGERY PF-EXCISION OF NECK CYST EACH 42810 $756.00 960 $529.20 $378.00 $604.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331481 PHYSICIAN FEE - SURGERY PF-EXCISION OF NECK CYST EACH 42815 "$1,446.00 " 960 "$1,012.20 " $723.00 "$1,156.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341332 PHYSICIAN FEE - SURGERY PF-EXCISION OF PENIS LESION(S) EACH 54060 $350.00 960 $245.00 $175.00 $280.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334808 PHYSICIAN FEE - SURGERY PF-EXCISION OF RECTAL LESION EACH 45160 "$2,908.00 " 960 "$2,035.60 " "$1,454.00 " "$2,326.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334766 PHYSICIAN FEE - SURGERY PF-EXCISION OF RECTAL PROLAPSE EACH 45130 "$2,944.00 " 960 "$2,060.80 " "$1,472.00 " "$2,355.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334774 PHYSICIAN FEE - SURGERY PF-EXCISION OF RECTAL PROLAPSE EACH 45135 "$3,455.00 " 960 "$2,418.50 " "$1,727.50 " "$2,764.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331200 PHYSICIAN FEE - SURGERY PF-EXCISION OF SALIVARY CYST EACH 42408 $911.00 960 $637.70 $455.50 $728.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346513 PHYSICIAN FEE - SURGERY PF-EXCISION OF SKULL TUMOR EACH 61563 "$5,986.00 " 960 "$4,190.20 " "$2,993.00 " "$4,788.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346521 PHYSICIAN FEE - SURGERY PF-EXCISION OF SKULL TUMOR EACH 61564 "$7,265.00 " 960 "$5,085.50 " "$3,632.50 " "$5,812.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346497 PHYSICIAN FEE - SURGERY PF-EXCISION OF SKULL/SUTURES EACH 61558 "$5,677.00 " 960 "$3,973.90 " "$2,838.50 " "$4,541.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346505 PHYSICIAN FEE - SURGERY PF-EXCISION OF SKULL/SUTURES EACH 61559 "$7,229.00 " 960 "$5,060.30 " "$3,614.50 " "$5,783.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332943 PHYSICIAN FEE - SURGERY PF-EXCISION OF STOMACH LESION EACH 43610 "$2,764.00 " 960 "$1,934.80 " "$1,382.00 " "$2,211.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332950 PHYSICIAN FEE - SURGERY PF-EXCISION OF STOMACH LESION EACH 43611 "$3,474.00 " 960 "$2,431.80 " "$1,737.00 " "$2,779.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330582 PHYSICIAN FEE - SURGERY PF-EXCISION OF TONGUE FOLD EACH 41115 $389.00 960 $272.30 $194.50 $311.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330566 PHYSICIAN FEE - SURGERY PF-EXCISION OF TONGUE LESION EACH 41113 $694.00 960 $485.80 $347.00 $555.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330574 PHYSICIAN FEE - SURGERY PF-EXCISION OF TONGUE LESION EACH 41114 "$1,662.00 " 960 "$1,163.40 " $831.00 "$1,329.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331606 PHYSICIAN FEE - SURGERY PF-EXCISION OF TONSIL TAGS EACH 42860 $522.00 960 $365.40 $261.00 $417.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337298 PHYSICIAN FEE - SURGERY PF-EXCISION OF UMBILICUS EACH 49250 "$1,663.00 " 960 "$1,164.10 " $831.50 "$1,330.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330947 PHYSICIAN FEE - SURGERY PF-EXCISION OF UVULA EACH 42140 $432.00 960 $302.40 $216.00 $345.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334790 PHYSICIAN FEE - SURGERY PF-EXCISION RECTAL STRICTURE EACH 45150 "$1,192.00 " 960 $834.40 $596.00 $953.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502405 PHYSICIAN FEE - SURGERY PF-EXCL LAA OPEN ANY METHOD EACH 33267 "$2,911.00 " 960 "$2,037.70 " "$1,455.50 " "$2,328.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502439 PHYSICIAN FEE - SURGERY PF-EXCL LAA THRSCP ANY METHOD EACH 33269 "$2,314.00 " 960 "$1,619.80 " "$1,157.00 " "$1,851.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321912 PHYSICIAN FEE - SURGERY PF-EXPL CHEST FREE ADHESIONS EACH 32124 "$2,570.00 " 960 "$1,799.00 " "$1,285.00 " "$2,056.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337157 PHYSICIAN FEE - SURGERY PF-EXPLORATION BEHIND ABDOMEN EACH 49010 "$2,597.00 " 960 "$1,817.90 " "$1,298.50 " "$2,077.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327265 PHYSICIAN FEE - SURGERY PF-EXPLORATION CAROTID ARTERY EACH 35701 "$1,185.00 " 960 $829.50 $592.50 $948.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342017 PHYSICIAN FEE - SURGERY PF-EXPLORATION FOR TESTIS EACH 54550 "$1,311.00 " 960 $917.70 $655.50 "$1,048.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342025 PHYSICIAN FEE - SURGERY PF-EXPLORATION FOR TESTIS EACH 54560 "$1,828.00 " 960 "$1,279.60 " $914.00 "$1,462.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320377 PHYSICIAN FEE - SURGERY PF-EXPLORATION FRONTAL SINUS EACH 31070 "$1,252.00 " 960 $876.40 $626.00 "$1,001.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320385 PHYSICIAN FEE - SURGERY PF-EXPLORATION FRONTAL SINUS EACH 31075 "$2,195.00 " 960 "$1,536.50 " "$1,097.50 " "$1,756.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320310 PHYSICIAN FEE - SURGERY PF-EXPLORATION MAXILLARY SINUS EACH 31020 $888.00 960 $621.60 $444.00 $710.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320328 PHYSICIAN FEE - SURGERY PF-EXPLORATION MAXILLARY SINUS EACH 31030 "$1,348.00 " 960 $943.60 $674.00 "$1,078.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320609 PHYSICIAN FEE - SURGERY PF-EXPLORATION MAXILLARY SINUS EACH 31256 $482.00 960 $337.40 $241.00 $385.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337132 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF ABDOMEN EACH 49000 "$2,159.00 " 960 "$1,511.30 " "$1,079.50 " "$1,727.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344815 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF ABDOMEN EACH 58960 "$2,720.00 " 960 "$1,904.00 " "$1,360.00 " "$2,176.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315666 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF ANKLE JOINT EACH 27612 "$1,546.00 " 960 "$1,082.20 " $773.00 "$1,236.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336688 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF BILE DUCTS EACH 47700 "$2,995.00 " 960 "$2,096.50 " "$1,497.50 " "$2,396.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321839 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF CHEST EACH 32035 "$2,048.00 " 960 "$1,433.60 " "$1,024.00 " "$1,638.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321847 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF CHEST EACH 32036 "$2,203.00 " 960 "$1,542.10 " "$1,101.50 " "$1,762.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329923 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF CHEST EACH 39000 "$1,398.00 " 960 $978.60 $699.00 "$1,118.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329931 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF CHEST EACH 39010 "$2,208.00 " 960 "$1,545.60 " "$1,104.00 " "$1,766.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316888 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF FOOT JOINT EACH 28022 $870.00 960 $609.00 $435.00 $696.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313158 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF HIP JOINT EACH 27033 "$2,674.00 " 960 "$1,871.80 " "$1,337.00 " "$2,139.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338122 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF KIDNEY EACH 50010 "$1,875.00 " 960 "$1,312.50 " $937.50 "$1,500.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338155 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF KIDNEY EACH 50045 "$2,473.00 " 960 "$1,731.10 " "$1,236.50 " "$1,978.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338239 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF KIDNEY EACH 50120 "$2,518.00 " 960 "$1,762.60 " "$1,259.00 " "$2,014.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338262 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF KIDNEY EACH 50135 "$2,968.00 " 960 "$2,077.60 " "$1,484.00 " "$2,374.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314289 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF KNEE JOINT EACH 27310 "$2,020.00 " 960 "$1,414.00 " "$1,010.00 " "$1,616.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353766 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF MIDDLE EAR EACH 69440 "$1,838.00 " 960 "$1,286.60 " $919.00 "$1,470.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320450 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF SINUSES EACH 31090 "$2,921.00 " 960 "$2,044.70 " "$1,460.50 " "$2,336.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316896 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF TOE JOINT EACH 28024 $815.00 960 $570.50 $407.50 $652.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338932 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF URETER EACH 50600 "$2,486.00 " 960 "$1,740.20 " "$1,243.00 " "$1,988.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342942 PHYSICIAN FEE - SURGERY PF-EXPLORATION OF VAGINA EACH 57000 $549.00 960 $384.30 $274.50 $439.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320351 PHYSICIAN FEE - SURGERY PF-EXPLORATION SPHENOID SINUS EACH 31050 "$1,367.00 " 960 $956.90 $683.50 "$1,093.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307283 PHYSICIAN FEE - SURGERY PF-EXPLORATION SPINAL FUSION EACH 22830 "$2,356.00 " 960 "$1,649.20 " "$1,178.00 " "$1,884.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321888 PHYSICIAN FEE - SURGERY PF-EXPLORATION/BIOPSY OF CHEST EACH 32100 "$2,265.00 " 960 "$1,585.50 " "$1,132.50 " "$1,812.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335276 PHYSICIAN FEE - SURGERY PF-EXPLORATION/REPAIR RECTUM EACH 45562 "$3,294.00 " 960 "$2,305.80 " "$1,647.00 " "$2,635.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335284 PHYSICIAN FEE - SURGERY PF-EXPLORATION/REPAIR RECTUM EACH 45563 "$4,679.00 " 960 "$3,275.30 " "$2,339.50 " "$3,743.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308588 PHYSICIAN FEE - SURGERY PF-EXPLORATORY ELBOW SURGERY EACH 24000 "$1,320.00 " 960 $924.00 $660.00 "$1,056.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323462 PHYSICIAN FEE - SURGERY PF-EXPLORATORY HEART SURGERY EACH 33310 "$3,237.00 " 960 "$2,265.90 " "$1,618.50 " "$2,589.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323470 PHYSICIAN FEE - SURGERY PF-EXPLORATORY HEART SURGERY EACH 33315 "$5,363.00 " 960 "$3,754.10 " "$2,681.50 " "$4,290.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307598 PHYSICIAN FEE - SURGERY PF-EXPLORATORY SHOULDER SURG EACH 23040 "$1,973.00 " 960 "$1,381.10 " $986.50 "$1,578.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307606 PHYSICIAN FEE - SURGERY PF-EXPLORATORY SHOULDER SURG EACH 23044 "$1,564.00 " 960 "$1,094.80 " $782.00 "$1,251.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327323 PHYSICIAN FEE - SURGERY PF-EXPLORE ABDOMINAL VESSELS EACH 35840 "$3,415.00 " 960 "$2,390.50 " "$1,707.50 " "$2,732.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345705 PHYSICIAN FEE - SURGERY PF-EXPLORE ADRENAL GLAND EACH 60545 "$3,500.00 " 960 "$2,450.00 " "$1,750.00 " "$2,800.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338247 PHYSICIAN FEE - SURGERY PF-EXPLORE AND DRAIN KIDNEY EACH 50125 "$2,605.00 " 960 "$1,823.50 " "$1,302.50 " "$2,084.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320344 PHYSICIAN FEE - SURGERY PF-EXPLORE BEHIND UPPER JAW EACH 31040 "$2,147.00 " 960 "$1,502.90 " "$1,073.50 " "$1,717.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327315 PHYSICIAN FEE - SURGERY PF-EXPLORE CHEST VESSELS EACH 35820 "$5,628.00 " 960 "$3,939.60 " "$2,814.00 " "$4,502.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329691 PHYSICIAN FEE - SURGERY PF-EXPLORE DEEP NODE(S) NECK EACH 38542 "$1,427.00 " 960 $998.90 $713.50 "$1,141.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342181 PHYSICIAN FEE - SURGERY PF-EXPLORE EPIDIDYMIS EACH 54865 $960.00 960 $672.00 $480.00 $768.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354269 PHYSICIAN FEE - SURGERY PF-EXPLORE INNER EAR EACH 69805 "$2,752.00 " 960 "$1,926.40 " "$1,376.00 " "$2,201.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354277 PHYSICIAN FEE - SURGERY PF-EXPLORE INNER EAR EACH 69806 "$2,459.00 " 960 "$1,721.30 " "$1,229.50 " "$1,967.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327331 PHYSICIAN FEE - SURGERY PF-EXPLORE LIMB VESSELS EACH 35860 "$2,360.00 " 960 "$1,652.00 " "$1,180.00 " "$1,888.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327307 PHYSICIAN FEE - SURGERY PF-EXPLORE NECK VESSELS EACH 35800 "$2,006.00 " 960 "$1,404.20 " "$1,003.00 " "$1,604.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346075 PHYSICIAN FEE - SURGERY PF-EXPLORE ORBIT/REMOVE LESION EACH 61333 "$6,095.00 " 960 "$4,266.50 " "$3,047.50 " "$4,876.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345622 PHYSICIAN FEE - SURGERY PF-EXPLORE PARATHYROID GLANDS EACH 60500 "$2,703.00 " 960 "$1,892.10 " "$1,351.50 " "$2,162.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345648 PHYSICIAN FEE - SURGERY PF-EXPLORE PARATHYROID GLANDS EACH 60505 "$3,867.00 " 960 "$2,706.90 " "$1,933.50 " "$3,093.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342264 PHYSICIAN FEE - SURGERY PF-EXPLORE SCROTUM EACH 55110 "$1,037.00 " 960 $725.90 $518.50 $829.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320336 PHYSICIAN FEE - SURGERY PF-EXPLORE SINUS REMOVE POLYPS EACH 31032 "$1,570.00 " 960 "$1,099.00 " $785.00 "$1,256.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333545 PHYSICIAN FEE - SURGERY PF-EXPLORE SMALL INTESTINE EACH 44020 "$2,748.00 " 960 "$1,923.60 " "$1,374.00 " "$2,198.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307739 PHYSICIAN FEE - SURGERY PF-EXPLORE TREAT SHOULDER JT EACH 23107 "$1,833.00 " 960 "$1,283.10 " $916.50 "$1,466.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303936 PHYSICIAN FEE - SURGERY PF-EXPLORE WOUND ABDOMEN EACH 20102 $720.00 960 $504.00 $360.00 $576.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303928 PHYSICIAN FEE - SURGERY PF-EXPLORE WOUND CHEST EACH 20101 $591.00 960 $413.70 $295.50 $472.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303944 PHYSICIAN FEE - SURGERY PF-EXPLORE WOUND EXTREMITY EACH 20103 $947.00 960 $662.90 $473.50 $757.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303910 PHYSICIAN FEE - SURGERY PF-EXPLORE WOUND NECK EACH 20100 "$1,673.00 " 960 "$1,171.10 " $836.50 "$1,338.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352461 PHYSICIAN FEE - SURGERY PF-EXPLORE/BIOPSY EYE SOCKET EACH 67400 "$2,651.00 " 960 "$1,855.70 " "$1,325.50 " "$2,120.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352560 PHYSICIAN FEE - SURGERY PF-EXPLORE/BIOPSY EYE SOCKET EACH 67450 "$3,558.00 " 960 "$2,490.60 " "$1,779.00 " "$2,846.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352479 PHYSICIAN FEE - SURGERY PF-EXPLORE/DRAIN EYE SOCKET EACH 67405 "$2,313.00 " 960 "$1,619.10 " "$1,156.50 " "$1,850.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352545 PHYSICIAN FEE - SURGERY PF-EXPLORE/DRAIN EYE SOCKET EACH 67440 "$3,436.00 " 960 "$2,405.20 " "$1,718.00 " "$2,748.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321896 PHYSICIAN FEE - SURGERY PF-EXPLORE/REPAIR CHEST EACH 32110 "$4,128.00 " 960 "$2,889.60 " "$2,064.00 " "$3,302.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315658 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT ANKLE JOINT EACH 27610 "$1,761.00 " 960 "$1,232.70 " $880.50 "$1,408.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315732 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT ANKLE JOINT EACH 27620 "$1,211.00 " 960 $847.70 $605.50 $968.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308695 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT ELBOW JOINT EACH 24101 "$1,384.00 " 960 $968.80 $692.00 "$1,107.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352537 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT EYE SOCKET EACH 67430 "$3,541.00 " 960 "$2,478.70 " "$1,770.50 " "$2,832.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311392 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT FINGER JOINT EACH 26075 $929.00 960 $650.30 $464.50 $743.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311400 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT FINGER JOINT EACH 26080 "$1,093.00 " 960 $765.10 $546.50 $874.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311384 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT HAND JOINT EACH 26070 $887.00 960 $620.90 $443.50 $709.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314370 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT KNEE JOINT EACH 27331 "$1,317.00 " 960 $921.90 $658.50 "$1,053.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309784 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT WRIST JOINT EACH 25040 "$1,538.00 " 960 "$1,076.60 " $769.00 "$1,230.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309891 PHYSICIAN FEE - SURGERY PF-EXPLORE/TREAT WRIST JOINT EACH 25101 "$1,118.00 " 960 $782.60 $559.00 $894.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352503 PHYSICIAN FEE - SURGERY PF-EXPLR/DECOMPRESS EYE SOCKET EACH 67414 "$3,742.00 " 960 "$2,619.40 " "$1,871.00 " "$2,993.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352552 PHYSICIAN FEE - SURGERY PF-EXPLR/DECOMPRESS EYE SOCKET EACH 67445 "$3,922.00 " 960 "$2,745.40 " "$1,961.00 " "$3,137.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353618 PHYSICIAN FEE - SURGERY PF-EXTENSIVE EAR CANAL SURGERY EACH 69150 "$2,690.00 " 960 "$1,883.00 " "$1,345.00 " "$2,152.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353626 PHYSICIAN FEE - SURGERY PF-EXTENSIVE EAR/NECK SURGERY EACH 69155 "$4,350.00 " 960 "$3,045.00 " "$2,175.00 " "$3,480.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311681 PHYSICIAN FEE - SURGERY PF-EXTENSIVE HAND SURGERY EACH 26250 "$2,936.00 " 960 "$2,055.20 " "$1,468.00 " "$2,348.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343916 PHYSICIAN FEE - SURGERY PF-EXTENSIVE HYSTERECTOMY EACH 58200 "$3,687.00 " 960 "$2,580.90 " "$1,843.50 " "$2,949.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343924 PHYSICIAN FEE - SURGERY PF-EXTENSIVE HYSTERECTOMY EACH 58210 "$4,979.00 " 960 "$3,485.30 " "$2,489.50 " "$3,983.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344013 PHYSICIAN FEE - SURGERY PF-EXTENSIVE HYSTERECTOMY EACH 58285 "$3,885.00 " 960 "$2,719.50 " "$1,942.50 " "$3,108.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304868 PHYSICIAN FEE - SURGERY PF-EXTENSIVE JAW SURGERY EACH 21045 "$3,205.00 " 960 "$2,243.50 " "$1,602.50 " "$2,564.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353816 PHYSICIAN FEE - SURGERY PF-EXTENSIVE MASTOID SURGERY EACH 69511 "$2,989.00 " 960 "$2,092.30 " "$1,494.50 " "$2,391.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353824 PHYSICIAN FEE - SURGERY PF-EXTENSIVE MASTOID SURGERY EACH 69530 "$4,433.00 " 960 "$3,103.10 " "$2,216.50 " "$3,546.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342520 PHYSICIAN FEE - SURGERY PF-EXTENSIVE PROSTATE SURGERY EACH 55810 "$3,460.00 " 960 "$2,422.00 " "$1,730.00 " "$2,768.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342538 PHYSICIAN FEE - SURGERY PF-EXTENSIVE PROSTATE SURGERY EACH 55812 "$4,254.00 " 960 "$2,977.80 " "$2,127.00 " "$3,403.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342546 PHYSICIAN FEE - SURGERY PF-EXTENSIVE PROSTATE SURGERY EACH 55815 "$4,658.00 " 960 "$3,260.60 " "$2,329.00 " "$3,726.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342579 PHYSICIAN FEE - SURGERY PF-EXTENSIVE PROSTATE SURGERY EACH 55840 "$3,105.00 " 960 "$2,173.50 " "$1,552.50 " "$2,484.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342587 PHYSICIAN FEE - SURGERY PF-EXTENSIVE PROSTATE SURGERY EACH 55842 "$3,103.00 " 960 "$2,172.10 " "$1,551.50 " "$2,482.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342595 PHYSICIAN FEE - SURGERY PF-EXTENSIVE PROSTATE SURGERY EACH 55845 "$3,611.00 " 960 "$2,527.70 " "$1,805.50 " "$2,888.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342611 PHYSICIAN FEE - SURGERY PF-EXTENSIVE PROSTATE SURGERY EACH 55862 "$2,902.00 " 960 "$2,031.40 " "$1,451.00 " "$2,321.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342629 PHYSICIAN FEE - SURGERY PF-EXTENSIVE PROSTATE SURGERY EACH 55865 "$3,532.00 " 960 "$2,472.40 " "$1,766.00 " "$2,825.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336159 PHYSICIAN FEE - SURGERY PF-EXTENSIVE REMOVAL OF LIVER EACH 47122 "$9,661.00 " 960 "$6,762.70 " "$4,830.50 " "$7,728.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343254 PHYSICIAN FEE - SURGERY PF-EXTENSIVE REPAIR OF VAGINA EACH 57265 "$2,378.00 " 960 "$1,664.60 " "$1,189.00 " "$1,902.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306467 PHYSICIAN FEE - SURGERY PF-EXTENSIVE STERNUM SURGERY EACH 21630 "$3,567.00 " 960 "$2,496.90 " "$1,783.50 " "$2,853.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306475 PHYSICIAN FEE - SURGERY PF-EXTENSIVE STERNUM SURGERY EACH 21632 "$3,407.00 " 960 "$2,384.90 " "$1,703.50 " "$2,725.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331572 PHYSICIAN FEE - SURGERY PF-EXTENSIVE SURGERY OF THROAT EACH 42842 "$2,674.00 " 960 "$1,871.80 " "$1,337.00 " "$2,139.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331580 PHYSICIAN FEE - SURGERY PF-EXTENSIVE SURGERY OF THROAT EACH 42844 "$3,642.00 " 960 "$2,549.40 " "$1,821.00 " "$2,913.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331598 PHYSICIAN FEE - SURGERY PF-EXTENSIVE SURGERY OF THROAT EACH 42845 "$5,856.00 " 960 "$4,099.20 " "$2,928.00 " "$4,684.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342009 PHYSICIAN FEE - SURGERY PF-EXTENSIVE TESTIS SURGERY EACH 54535 "$1,978.00 " 960 "$1,384.60 " $989.00 "$1,582.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345556 PHYSICIAN FEE - SURGERY PF-EXTENSIVE THYROID SURGERY EACH 60254 "$4,597.00 " 960 "$3,217.90 " "$2,298.50 " "$3,677.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342801 PHYSICIAN FEE - SURGERY PF-EXTENSIVE VULVA SURGERY EACH 56630 "$2,620.00 " 960 "$1,834.00 " "$1,310.00 " "$2,096.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342819 PHYSICIAN FEE - SURGERY PF-EXTENSIVE VULVA SURGERY EACH 56631 "$3,241.00 " 960 "$2,268.70 " "$1,620.50 " "$2,592.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342827 PHYSICIAN FEE - SURGERY PF-EXTENSIVE VULVA SURGERY EACH 56632 "$3,908.00 " 960 "$2,735.60 " "$1,954.00 " "$3,126.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342835 PHYSICIAN FEE - SURGERY PF-EXTENSIVE VULVA SURGERY EACH 56633 "$3,384.00 " 960 "$2,368.80 " "$1,692.00 " "$2,707.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342843 PHYSICIAN FEE - SURGERY PF-EXTENSIVE VULVA SURGERY EACH 56634 "$3,540.00 " 960 "$2,478.00 " "$1,770.00 " "$2,832.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342850 PHYSICIAN FEE - SURGERY PF-EXTENSIVE VULVA SURGERY EACH 56637 "$4,151.00 " 960 "$2,905.70 " "$2,075.50 " "$3,320.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342868 PHYSICIAN FEE - SURGERY PF-EXTENSIVE VULVA SURGERY EACH 56640 "$4,171.00 " 960 "$2,919.70 " "$2,085.50 " "$3,336.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328636 PHYSICIAN FEE - SURGERY PF-EXTERNAL CANNULA DECLOTTING EACH 36860 $312.00 960 $218.40 $156.00 $249.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351869 PHYSICIAN FEE - SURGERY PF-EXTRACTION OF LENS EACH 66920 "$1,912.00 " 960 "$1,338.40 " $956.00 "$1,529.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351877 PHYSICIAN FEE - SURGERY PF-EXTRACTION OF LENS EACH 66930 "$2,191.00 " 960 "$1,533.70 " "$1,095.50 " "$1,752.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351885 PHYSICIAN FEE - SURGERY PF-EXTRACTION OF LENS EACH 66940 "$2,004.00 " 960 "$1,402.80 " "$1,002.00 " "$1,603.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352263 PHYSICIAN FEE - SURGERY PF-EYE PHOTODYNAMIC THER ADDON EACH 67225 $71.00 960 $49.70 $35.50 $56.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352388 PHYSICIAN FEE - SURGERY PF-EYE SURG FOLLOW-UP ADD-ON EACH 67331 $397.00 960 $277.90 $198.50 $317.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357668 PHYSICIAN FEE - SURGERY PF-EYE SURGERY PROC NOS EACH 66999 "$3,465.00 " 960 "$2,425.50 " "$1,732.50 " "$2,772.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352412 PHYSICIAN FEE - SURGERY PF-EYE SUTURE DURING SURGERY EACH 67335 $476.00 960 $333.20 $238.00 $380.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357445 PHYSICIAN FEE - SURGERY PF-EYELID UNLISTED PROCEDURE EACH 67999 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305485 PHYSICIAN FEE - SURGERY PF-FACE BONE GRAFT EACH 21210 "$1,984.00 " 960 "$1,388.80 " $992.00 "$1,587.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328958 PHYSICIAN FEE - SURGERY PF-FEM/POPL REVAS W/ATHER EACH 37225 "$1,650.00 " 960 "$1,155.00 " $825.00 "$1,320.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328974 PHYSICIAN FEE - SURGERY PF-FEM/POPL REVSC STNT & ATHER EACH 37227 "$1,976.00 " 960 "$1,383.20 " $988.00 "$1,580.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325673 PHYSICIAN FEE - SURGERY PF-FEMORAL ENDOVAS GRFT ADD-ON EACH 34813 $665.00 960 $465.50 $332.50 $532.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358625 PHYSICIAN FEE - SURGERY PF-FEMUR OR KNEE PROCEDURE NOS EACH 34712 "$1,826.00 " 960 "$1,278.20 " $913.00 "$1,460.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344898 PHYSICIAN FEE - SURGERY PF-FETAL CONTRACT STRESS TEST EACH 59020 $89.00 960 $62.30 $44.50 $71.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344963 PHYSICIAN FEE - SURGERY PF-FETAL FLUID DRAINAGE W/US EACH 59074 $899.00 960 $629.30 $449.50 $719.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344922 PHYSICIAN FEE - SURGERY PF-FETAL MONITOR W/REPORT EACH 59050 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344906 PHYSICIAN FEE - SURGERY PF-FETAL NON-STRESS TEST EACH 59025 $52.00 960 $36.40 $26.00 $41.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344914 PHYSICIAN FEE - SURGERY PF-FETAL SCALP BLOOD SAMPLE EACH 59030 $328.00 960 $229.60 $164.00 $262.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344971 PHYSICIAN FEE - SURGERY PF-FETAL SHUNT PLACEMENT W/US EACH 59076 "$1,520.00 " 960 "$1,064.00 " $760.00 "$1,216.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304579 PHYSICIAN FEE - SURGERY PF-FIBULA BONE GRAFT MICROVASC EACH 20955 "$6,581.00 " 960 "$4,606.70 " "$3,290.50 " "$5,264.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344617 PHYSICIAN FEE - SURGERY PF-FIMBRIOPLASTY EACH 58760 "$2,246.00 " 960 "$1,572.20 " "$1,123.00 " "$1,796.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312176 PHYSICIAN FEE - SURGERY PF-FINGER TENDON TRANSFER EACH 26497 "$2,454.00 " 960 "$1,717.80 " "$1,227.00 " "$1,963.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312184 PHYSICIAN FEE - SURGERY PF-FINGER TENDON TRANSFER EACH 26498 "$3,209.00 " 960 "$2,246.30 " "$1,604.50 " "$2,567.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343437 PHYSICIAN FEE - SURGERY PF-FISTULA REPAIR & COLOSTOMY EACH 57307 "$2,884.00 " 960 "$2,018.80 " "$1,442.00 " "$2,307.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343445 PHYSICIAN FEE - SURGERY PF-FISTULA REPAIR TRANSPERINE EACH 57308 "$1,780.00 " 960 "$1,246.00 " $890.00 "$1,424.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343163 PHYSICIAN FEE - SURGERY PF-FITTING OF DIAPHRAGM/CAP EACH 57170 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337652 PHYSICIAN FEE - SURGERY PF-FIX G/COLON TUBE W/DEVICE EACH 49460 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316672 PHYSICIAN FEE - SURGERY PF-FIXATION OF ANKLE JOINT EACH 27860 $439.00 960 $307.30 $219.50 $351.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315492 PHYSICIAN FEE - SURGERY PF-FIXATION OF KNEE JOINT EACH 27570 $422.00 960 $295.40 $211.00 $337.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308497 PHYSICIAN FEE - SURGERY PF-FIXATION OF SHOULDER EACH 23700 $537.00 960 $375.90 $268.50 $429.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307986 PHYSICIAN FEE - SURGERY PF-FIXATION OF SHOULDER BLADE EACH 23400 "$2,680.00 " 960 "$1,876.00 " "$1,340.00 " "$2,144.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302698 PHYSICIAN FEE - SURGERY PF-FLAP FOR FACE NERVE PALSY EACH 15842 "$7,317.00 " 960 "$5,121.90 " "$3,658.50 " "$5,853.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304561 PHYSICIAN FEE - SURGERY PF-FLUID PRESSURE MUSCLE EACH 20950 $240.00 960 $168.00 $120.00 $192.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337660 PHYSICIAN FEE - SURGERY PF-FLUORO EXAM OF G/COLON TUBE EACH 49465 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359078 PHYSICIAN FEE - SURGERY PF-FNA W CT GUIDANCE - 1ST EACH 10009 $283.00 960 $198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359086 PHYSICIAN FEE - SURGERY PF-FNA W CT GUIDANCE EA ADDL EACH 10010 $194.00 960 $135.80 $97.00 $155.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358377 PHYSICIAN FEE - SURGERY PF-FNA W FLUORO GUIDANCE - 1ST EACH 10007 $238.00 960 $166.60 $119.00 $190.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359094 PHYSICIAN FEE - SURGERY PF-FNA W MR GUIDANCE - 1ST EACH 10011 $283.00 960 $198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359102 PHYSICIAN FEE - SURGERY PF-FNA W MR GUIDANCE EA ADDL EACH 10012 $194.00 960 $135.80 $97.00 $155.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359037 PHYSICIAN FEE - SURGERY PF-FNA W US GUIDANCE - 1ST EACH 10005 $192.00 960 $134.40 $96.00 $153.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359045 PHYSICIAN FEE - SURGERY PF-FNA W US GUIDANCE EA ADDL EACH 10006 $131.00 960 $91.70 $65.50 $104.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300015 PHYSICIAN FEE - SURGERY PF-FNA W/IMAGE EACH 10004 $118.00 960 $82.60 $59.00 $94.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357924 PHYSICIAN FEE - SURGERY PF-FOREARM/WRIST SURGERY NOS EACH 25999 "$1,344.00 " 960 $940.80 $672.00 "$1,075.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302284 PHYSICIAN FEE - SURGERY PF-FOREHD FLAP W/VASC PEDICLE EACH 15731 "$2,665.00 " 960 "$1,865.50 " "$1,332.50 " "$2,132.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302193 PHYSICIAN FEE - SURGERY PF-FORM SKIN PEDICLE FLAP EACH 15570 "$1,983.00 " 960 "$1,388.10 " $991.50 "$1,586.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302201 PHYSICIAN FEE - SURGERY PF-FORM SKIN PEDICLE FLAP EACH 15572 "$1,988.00 " 960 "$1,391.60 " $994.00 "$1,590.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338908 PHYSICIAN FEE - SURGERY PF-FRAGMENTING OF KIDNEY STONE EACH 50590 "$1,522.00 " 960 "$1,065.40 " $761.00 "$1,217.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302375 PHYSICIAN FEE - SURGERY PF-FREE FASCIAL FLAP MICROVASC EACH 15758 "$6,077.00 " 960 "$4,253.90 " "$3,038.50 " "$4,861.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332877 PHYSICIAN FEE - SURGERY PF-FREE JEJUNUM FLAP MICROVASC EACH 43496 "$5,866.00 " 960 "$4,106.20 " "$2,933.00 " "$4,692.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302359 PHYSICIAN FEE - SURGERY PF-FREE MYO/SKIN FLAP MICROVSC EACH 15756 "$6,162.00 " 960 "$4,313.40 " "$3,081.00 " "$4,929.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338114 PHYSICIAN FEE - SURGERY PF-FREE OMENTAL FLAP MICROVASC EACH 49906 "$5,866.00 " 960 "$4,106.20 " "$2,933.00 " "$4,692.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302367 PHYSICIAN FEE - SURGERY PF-FREE SKIN FLAP MICROVASC EACH 15757 "$6,106.00 " 960 "$4,274.20 " "$3,053.00 " "$4,884.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322027 PHYSICIAN FEE - SURGERY PF-FREE/REMOVE CHEST LINING EACH 32320 "$4,486.00 " 960 "$3,140.20 " "$2,243.00 " "$3,588.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333511 PHYSICIAN FEE - SURGERY PF-FREEING OF BOWEL ADHESION EACH 44005 "$3,080.00 " 960 "$2,156.00 " "$1,540.00 " "$2,464.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341506 PHYSICIAN FEE - SURGERY PF-FRENULOTOMY OF PENIS EACH 54164 $517.00 960 $361.90 $258.50 $413.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302086 PHYSICIAN FEE - SURGERY PF-FULL GR ADDL 20CM F/C/M/H/F EACH 15241 $290.00 960 $203.00 $145.00 $232.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302102 PHYSICIAN FEE - SURGERY PF-FULL GRFT ADDL 20CM N/E/E/L EACH 15261 $361.00 960 $252.70 $180.50 $288.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336779 PHYSICIAN FEE - SURGERY PF-FUSE BILE DUCTS AND BOWEL EACH 47760 "$6,368.00 " 960 "$4,457.60 " "$3,184.00 " "$5,094.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336795 PHYSICIAN FEE - SURGERY PF-FUSE BILE DUCTS AND BOWEL EACH 47780 "$7,024.00 " 960 "$4,916.80 " "$3,512.00 " "$5,619.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336803 PHYSICIAN FEE - SURGERY PF-FUSE BILE DUCTS AND BOWEL EACH 47785 "$9,177.00 " 960 "$6,423.90 " "$4,588.50 " "$7,341.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332711 PHYSICIAN FEE - SURGERY PF-FUSE ESOPHAGUS & INTESTINE EACH 43340 "$3,922.00 " 960 "$2,745.40 " "$1,961.00 " "$3,137.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332729 PHYSICIAN FEE - SURGERY PF-FUSE ESOPHAGUS & INTESTINE EACH 43341 "$2,958.00 " 960 "$2,070.60 " "$1,479.00 " "$2,366.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332588 PHYSICIAN FEE - SURGERY PF-FUSE ESOPHAGUS & STOMACH EACH 43320 "$3,971.00 " 960 "$2,779.70 " "$1,985.50 " "$3,176.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336738 PHYSICIAN FEE - SURGERY PF-FUSE GALLBLADDER & BOWEL EACH 47720 "$3,268.00 " 960 "$2,287.60 " "$1,634.00 " "$2,614.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336753 PHYSICIAN FEE - SURGERY PF-FUSE GALLBLADDER & BOWEL EACH 47740 "$3,722.00 " 960 "$2,605.40 " "$1,861.00 " "$2,977.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336761 PHYSICIAN FEE - SURGERY PF-FUSE GALLBLADDER & BOWEL EACH 47741 "$4,184.00 " 960 "$2,928.80 " "$2,092.00 " "$3,347.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311137 PHYSICIAN FEE - SURGERY PF-FUSE HAND BONES WITH GRAFT EACH 25825 "$2,158.00 " 960 "$1,510.60 " "$1,079.00 " "$1,726.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336837 PHYSICIAN FEE - SURGERY PF-FUSE LIVER DUCT & INTESTINE EACH 47802 "$4,321.00 " 960 "$3,024.70 " "$2,160.50 " "$3,456.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336787 PHYSICIAN FEE - SURGERY PF-FUSE LIVER DUCTS & BOWEL EACH 47765 "$8,611.00 " 960 "$6,027.70 " "$4,305.50 " "$6,888.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337082 PHYSICIAN FEE - SURGERY PF-FUSE PANCREAS AND BOWEL EACH 48548 "$4,750.00 " 960 "$3,325.00 " "$2,375.00 " "$3,800.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337041 PHYSICIAN FEE - SURGERY PF-FUSE PANCREAS CYST & BOWEL EACH 48520 "$3,122.00 " 960 "$2,185.40 " "$1,561.00 " "$2,497.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337058 PHYSICIAN FEE - SURGERY PF-FUSE PANCREAS CYST & BOWEL EACH 48540 "$3,715.00 " 960 "$2,600.50 " "$1,857.50 " "$2,972.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336746 PHYSICIAN FEE - SURGERY PF-FUSE UPPER GI STRUCTURES EACH 47721 "$3,840.00 " 960 "$2,688.00 " "$1,920.00 " "$3,072.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313000 PHYSICIAN FEE - SURGERY PF-FUSE/GRAFT ADDED JOINT EACH 26863 $622.00 960 $435.40 $311.00 $497.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318488 PHYSICIAN FEE - SURGERY PF-FUSION BIG TOE JOINT-JONES EACH 28760 "$1,524.00 " 960 "$1,066.80 " $762.00 "$1,219.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318470 PHYSICIAN FEE - SURGERY PF-FUSION BIG TOE JT-INTRPHLNL EACH 28755 $891.00 960 $623.70 $445.50 $712.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318462 PHYSICIAN FEE - SURGERY PF-FUSION BIG TOE JT-MTTRSPHLN EACH 28750 "$1,543.00 " 960 "$1,080.10 " $771.50 "$1,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350580 PHYSICIAN FEE - SURGERY PF-FUSION FACIAL/OTHER NERVE EACH 64866 "$3,354.00 " 960 "$2,347.80 " "$1,677.00 " "$2,683.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350598 PHYSICIAN FEE - SURGERY PF-FUSION FACIAL/OTHER NERVE EACH 64868 "$2,662.00 " 960 "$1,863.40 " "$1,331.00 " "$2,129.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318454 PHYSICIAN FEE - SURGERY PF-FUSION FOOT BONES - SNGL JT EACH 28740 "$1,654.00 " 960 "$1,157.80 " $827.00 "$1,323.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318397 PHYSICIAN FEE - SURGERY PF-FUSION FOOT BONES-PANTALAR EACH 28705 "$3,301.00 " 960 "$2,310.70 " "$1,650.50 " "$2,640.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318421 PHYSICIAN FEE - SURGERY PF-FUSION FT BONES MULT/TRANSV EACH 28730 "$1,953.00 " 960 "$1,367.10 " $976.50 "$1,562.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318439 PHYSICIAN FEE - SURGERY PF-FUSION FT BONES W/OSTEOTOMY EACH 28735 "$2,089.00 " 960 "$1,462.30 " "$1,044.50 " "$1,671.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312960 PHYSICIAN FEE - SURGERY PF-FUSION KNUCKLE WITH GRAFT EACH 26852 "$2,246.00 " 960 "$1,572.20 " "$1,123.00 " "$1,796.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316680 PHYSICIAN FEE - SURGERY PF-FUSION OF ANKLE JOINT OPEN EACH 27870 "$2,747.00 " 960 "$1,922.90 " "$1,373.50 " "$2,197.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309602 PHYSICIAN FEE - SURGERY PF-FUSION OF ELBOW JOINT EACH 24800 "$2,299.00 " 960 "$1,609.30 " "$1,149.50 " "$1,839.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312986 PHYSICIAN FEE - SURGERY PF-FUSION OF FINGER JNT ADD-ON EACH 26861 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312978 PHYSICIAN FEE - SURGERY PF-FUSION OF FINGER JOINT EACH 26860 "$1,633.00 " 960 "$1,143.10 " $816.50 "$1,306.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312036 PHYSICIAN FEE - SURGERY PF-FUSION OF FINGER TENDONS EACH 26471 "$1,768.00 " 960 "$1,237.60 " $884.00 "$1,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312044 PHYSICIAN FEE - SURGERY PF-FUSION OF FINGER TENDONS EACH 26474 "$1,751.00 " 960 "$1,225.70 " $875.50 "$1,400.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318405 PHYSICIAN FEE - SURGERY PF-FUSION OF FOOT BONES-TRIPLE EACH 28715 "$2,548.00 " 960 "$1,783.60 " "$1,274.00 " "$2,038.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311129 PHYSICIAN FEE - SURGERY PF-FUSION OF HAND BONES EACH 25820 "$1,768.00 " 960 "$1,237.60 " $884.00 "$1,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312937 PHYSICIAN FEE - SURGERY PF-FUSION OF HAND JOINT EACH 26843 "$2,114.00 " 960 "$1,479.80 " "$1,057.00 " "$1,691.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314198 PHYSICIAN FEE - SURGERY PF-FUSION OF HIP JOINT EACH 27284 "$4,419.00 " 960 "$3,093.30 " "$2,209.50 " "$3,535.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314206 PHYSICIAN FEE - SURGERY PF-FUSION OF HIP JOINT EACH 27286 "$4,522.00 " 960 "$3,165.40 " "$2,261.00 " "$3,617.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315500 PHYSICIAN FEE - SURGERY PF-FUSION OF KNEE EACH 27580 "$4,055.00 " 960 "$2,838.50 " "$2,027.50 " "$3,244.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312952 PHYSICIAN FEE - SURGERY PF-FUSION OF KNUCKLE EACH 26850 "$1,971.00 " 960 "$1,379.70 " $985.50 "$1,576.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312242 PHYSICIAN FEE - SURGERY PF-FUSION OF KNUCKLE JOINT EACH 26516 "$1,998.00 " 960 "$1,398.60 " $999.00 "$1,598.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312259 PHYSICIAN FEE - SURGERY PF-FUSION OF KNUCKLE JOINTS EACH 26517 "$2,344.00 " 960 "$1,640.80 " "$1,172.00 " "$1,875.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312267 PHYSICIAN FEE - SURGERY PF-FUSION OF KNUCKLE JOINTS EACH 26518 "$2,375.00 " 960 "$1,662.50 " "$1,187.50 " "$1,900.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314180 PHYSICIAN FEE - SURGERY PF-FUSION OF PUBIC BONES EACH 27282 "$2,369.00 " 960 "$1,658.30 " "$1,184.50 " "$1,895.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314172 PHYSICIAN FEE - SURGERY PF-FUSION OF SACROILIAC JOINT EACH 27280 "$3,907.00 " 960 "$2,734.90 " "$1,953.50 " "$3,125.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308505 PHYSICIAN FEE - SURGERY PF-FUSION OF SHOULDER JOINT EACH 23800 "$2,831.00 " 960 "$1,981.70 " "$1,415.50 " "$2,264.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308513 PHYSICIAN FEE - SURGERY PF-FUSION OF SHOULDER JOINT EACH 23802 "$3,531.00 " 960 "$2,471.70 " "$1,765.50 " "$2,824.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347073 PHYSICIAN FEE - SURGERY PF-FUSION OF SKULL ARTERIES EACH 61711 "$7,875.00 " 960 "$5,512.50 " "$3,937.50 " "$6,300.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342199 PHYSICIAN FEE - SURGERY PF-FUSION OF SPERMATIC DUCTS EACH 54900 "$2,124.00 " 960 "$1,486.80 " "$1,062.00 " "$1,699.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342207 PHYSICIAN FEE - SURGERY PF-FUSION OF SPERMATIC DUCTS EACH 54901 "$2,805.00 " 960 "$1,963.50 " "$1,402.50 " "$2,244.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307200 PHYSICIAN FEE - SURGERY PF-FUSION OF SPINE EACH 22800 "$3,896.00 " 960 "$2,727.20 " "$1,948.00 " "$3,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307218 PHYSICIAN FEE - SURGERY PF-FUSION OF SPINE EACH 22802 "$6,056.00 " 960 "$4,239.20 " "$3,028.00 " "$4,844.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307226 PHYSICIAN FEE - SURGERY PF-FUSION OF SPINE EACH 22804 "$6,944.00 " 960 "$4,860.80 " "$3,472.00 " "$5,555.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307234 PHYSICIAN FEE - SURGERY PF-FUSION OF SPINE EACH 22808 "$5,278.00 " 960 "$3,694.60 " "$2,639.00 " "$4,222.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307242 PHYSICIAN FEE - SURGERY PF-FUSION OF SPINE EACH 22810 "$5,533.00 " 960 "$3,873.10 " "$2,766.50 " "$4,426.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307259 PHYSICIAN FEE - SURGERY PF-FUSION OF SPINE EACH 22812 "$6,060.00 " 960 "$4,242.00 " "$3,030.00 " "$4,848.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333289 PHYSICIAN FEE - SURGERY PF-FUSION OF STOMACH AND BOWEL EACH 43810 "$2,891.00 " 960 "$2,023.70 " "$1,445.50 " "$2,312.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333297 PHYSICIAN FEE - SURGERY PF-FUSION OF STOMACH AND BOWEL EACH 43820 "$3,808.00 " 960 "$2,665.60 " "$1,904.00 " "$3,046.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333305 PHYSICIAN FEE - SURGERY PF-FUSION OF STOMACH AND BOWEL EACH 43825 "$3,728.00 " 960 "$2,609.60 " "$1,864.00 " "$2,982.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310295 PHYSICIAN FEE - SURGERY PF-FUSION OF TENDONS AT WRIST EACH 25300 "$1,904.00 " 960 "$1,332.80 " $952.00 "$1,523.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310303 PHYSICIAN FEE - SURGERY PF-FUSION OF TENDONS AT WRIST EACH 25301 "$1,768.00 " 960 "$1,237.60 " $884.00 "$1,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312911 PHYSICIAN FEE - SURGERY PF-FUSION OF THUMB EACH 26841 "$2,084.00 " 960 "$1,458.80 " "$1,042.00 " "$1,667.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317605 PHYSICIAN FEE - SURGERY PF-FUSION OF TOES EACH 28280 $913.00 960 $639.10 $456.50 $730.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339195 PHYSICIAN FEE - SURGERY PF-FUSION OF URETER & BOWEL EACH 50810 "$3,986.00 " 960 "$2,790.20 " "$1,993.00 " "$3,188.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339104 PHYSICIAN FEE - SURGERY PF-FUSION OF URETER & KIDNEY EACH 50740 "$3,480.00 " 960 "$2,436.00 " "$1,740.00 " "$2,784.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339112 PHYSICIAN FEE - SURGERY PF-FUSION OF URETER & KIDNEY EACH 50750 "$3,054.00 " 960 "$2,137.80 " "$1,527.00 " "$2,443.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339120 PHYSICIAN FEE - SURGERY PF-FUSION OF URETERS EACH 50760 "$3,059.00 " 960 "$2,141.30 " "$1,529.50 " "$2,447.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311095 PHYSICIAN FEE - SURGERY PF-FUSION OF WRIST JOINT EACH 25800 "$2,004.00 " 960 "$1,402.80 " "$1,002.00 " "$1,603.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311145 PHYSICIAN FEE - SURGERY PF-FUSION RADIOULNAR JNT/ULNA EACH 25830 "$2,783.00 " 960 "$1,948.10 " "$1,391.50 " "$2,226.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316698 PHYSICIAN FEE - SURGERY PF-FUSION TIBIOFIBULAR JOINT EACH 27871 "$1,894.00 " 960 "$1,325.80 " $947.00 "$1,515.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312994 PHYSICIAN FEE - SURGERY PF-FUSION/GRAFT FINGER JOINT EACH 26862 "$2,062.00 " 960 "$1,443.40 " "$1,031.00 " "$1,649.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309610 PHYSICIAN FEE - SURGERY PF-FUSION/GRAFT OF ELBOW JOINT EACH 24802 "$2,762.00 " 960 "$1,933.40 " "$1,381.00 " "$2,209.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312945 PHYSICIAN FEE - SURGERY PF-FUSION/GRAFT OF HAND JOINT EACH 26844 "$2,328.00 " 960 "$1,629.60 " "$1,164.00 " "$1,862.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311103 PHYSICIAN FEE - SURGERY PF-FUSION/GRAFT OF WRIST JOINT EACH 25805 "$2,338.00 " 960 "$1,636.60 " "$1,169.00 " "$1,870.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311111 PHYSICIAN FEE - SURGERY PF-FUSION/GRAFT OF WRIST JOINT EACH 25810 "$2,375.00 " 960 "$1,662.50 " "$1,187.50 " "$1,900.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333370 PHYSICIAN FEE - SURGERY PF-GASTRIC BYPASS FOR OBESITY EACH 43846 "$4,693.00 " 960 "$3,285.10 " "$2,346.50 " "$3,754.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333388 PHYSICIAN FEE - SURGERY PF-GASTRIC BYPASS INCL SMALL I EACH 43847 "$5,138.00 " 960 "$3,596.60 " "$2,569.00 " "$4,110.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332752 PHYSICIAN FEE - SURGERY PF-GASTROINTESTINAL REPAIR EACH 43360 "$6,333.00 " 960 "$4,433.10 " "$3,166.50 " "$5,066.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332760 PHYSICIAN FEE - SURGERY PF-GASTROINTESTINAL REPAIR EACH 43361 "$7,663.00 " 960 "$5,364.10 " "$3,831.50 " "$6,130.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333354 PHYSICIAN FEE - SURGERY PF-GASTROPLASTY W/O V-BAND EACH 43843 "$3,649.00 " 960 "$2,554.30 " "$1,824.50 " "$2,919.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333362 PHYSICIAN FEE - SURGERY PF-GASTROPLSTY DUODENAL SWITCH EACH 43845 "$5,566.00 " 960 "$3,896.20 " "$2,783.00 " "$4,452.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357783 PHYSICIAN FEE - SURGERY PF-GENITAL SURGERY PROC NOS EACH 55899 "$5,270.00 " 960 "$3,689.00 " "$2,635.00 " "$4,216.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359193 PHYSICIAN FEE - SURGERY PF-GENITAL SURGERY PROC NOS EACH 58999 $785.00 960 $549.50 $392.50 $628.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359219 PHYSICIAN FEE - SURGERY PF-GI TRACT CAPSULE ENDOSCOPY EACH 91110 $280.00 960 $196.00 $140.00 $224.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351497 PHYSICIAN FEE - SURGERY PF-GLAUCOMA SURGERY EACH 66150 "$2,243.00 " 960 "$1,570.10 " "$1,121.50 " "$1,794.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351505 PHYSICIAN FEE - SURGERY PF-GLAUCOMA SURGERY EACH 66155 "$2,241.00 " 960 "$1,568.70 " "$1,120.50 " "$1,792.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351513 PHYSICIAN FEE - SURGERY PF-GLAUCOMA SURGERY EACH 66160 "$2,521.00 " 960 "$1,764.70 " "$1,260.50 " "$2,016.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302417 PHYSICIAN FEE - SURGERY PF-GR HAIR TRNSPL >15 PNCH GFT EACH 15776 $951.00 960 $665.70 $475.50 $760.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302672 PHYSICIAN FEE - SURGERY PF-GRAFT FOR FACE NERVE PALSY EACH 15840 "$2,714.00 " 960 "$1,899.80 " "$1,357.00 " "$2,171.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302680 PHYSICIAN FEE - SURGERY PF-GRAFT FOR FACE NERVE PALSY EACH 15841 "$4,820.00 " 960 "$3,374.00 " "$2,410.00 " "$3,856.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302409 PHYSICIAN FEE - SURGERY PF-GRAFT HAIR TRNSPL 1-15 PNCH EACH 15775 $692.00 960 $484.40 $346.00 $553.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311871 PHYSICIAN FEE - SURGERY PF-GRAFT HAND OR FINGER TENDON EACH 26416 "$2,490.00 " 960 "$1,743.00 " "$1,245.00 " "$1,992.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349137 PHYSICIAN FEE - SURGERY PF-GRAFT REPAIR SPINE DEFECT EACH 63710 "$3,108.00 " 960 "$2,175.60 " "$1,554.00 " "$2,486.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312408 PHYSICIAN FEE - SURGERY PF-GREAT TOE-HAND TRANSFER EACH 26551 "$9,032.00 " 960 "$6,322.40 " "$4,516.00 " "$7,225.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360399 PHYSICIAN FEE - SURGERY PF-GRF AUTOL SOFT TISS DIR EXC EACH 15769 "$1,307.00 " 960 $914.90 $653.50 "$1,045.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300023 PHYSICIAN FEE - SURGERY PF-GUIDE CATHET FLUID DRAINAGE EACH 10030 $355.00 960 $248.50 $177.50 $284.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312200 PHYSICIAN FEE - SURGERY PF-HAND TENDON RECONSTRUCTION EACH 26500 "$1,850.00 " 960 "$1,295.00 " $925.00 "$1,480.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312218 PHYSICIAN FEE - SURGERY PF-HAND TENDON RECONSTRUCTION EACH 26502 "$2,041.00 " 960 "$1,428.70 " "$1,020.50 " "$1,632.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312150 PHYSICIAN FEE - SURGERY PF-HAND TENDON/MUSCLE TRANSFER EACH 26494 "$2,278.00 " 960 "$1,594.60 " "$1,139.00 " "$1,822.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329477 PHYSICIAN FEE - SURGERY PF-HARVEST ALLOGEN STEM CELLS EACH 38205 $215.00 960 $150.50 $107.50 $172.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326887 PHYSICIAN FEE - SURGERY PF-HARVEST ART FOR CABG ADD-ON EACH 35600 $521.00 960 $364.70 $260.50 $416.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329485 PHYSICIAN FEE - SURGERY PF-HARVEST AUTO STEM CELLS EACH 38206 $211.00 960 $147.70 $105.50 $168.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301831 PHYSICIAN FEE - SURGERY PF-HARVEST CULTURED SKIN GRAFT EACH 15040 $343.00 960 $240.10 $171.50 $274.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353253 PHYSICIAN FEE - SURGERY PF-HARVEST EYE TISSUE ALOGRAFT EACH 68371 "$1,054.00 " 960 $737.80 $527.00 $843.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326846 PHYSICIAN FEE - SURGERY PF-HARVEST FEMOROPOPLIT VEIN EACH 35572 $966.00 960 $676.20 $483.00 $772.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326523 PHYSICIAN FEE - SURGERY PF-HARVEST VEIN FOR BYPASS EACH 35500 $898.00 960 $628.60 $449.00 $718.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357700 PHYSICIAN FEE - SURGERY PF-HEAD SURGERY PROCEDURE NOS EACH 21499 "$1,716.00 " 960 "$1,201.20 " $858.00 "$1,372.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322894 PHYSICIAN FEE - SURGERY PF-HEART REVASCULARIZE (TMR) EACH 33140 "$4,320.00 " 960 "$3,024.00 " "$2,160.00 " "$3,456.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322902 PHYSICIAN FEE - SURGERY PF-HEART TMR W/OTHER PROCEDURE EACH 33141 $371.00 960 $259.70 $185.50 $296.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359334 PHYSICIAN FEE - SURGERY PF-HEMICRT INTRCLRY ALGRFT PRT EACH 20933 "$1,908.00 " 960 "$1,335.60 " $954.00 "$1,526.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336084 PHYSICIAN FEE - SURGERY PF-HEMORRHOIDOPEXY BY STAPLING EACH 46947 "$1,079.00 " 960 $755.30 $539.50 $863.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318546 PHYSICIAN FEE - SURGERY PF-HIGH ENERGY ESWT PLANTAR F EACH 28890 $587.00 960 $410.90 $293.50 $469.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319429 PHYSICIAN FEE - SURGERY PF-HIP ARTHR0 W/DEBRIDEMENT EACH 29862 "$2,238.00 " 960 "$1,566.60 " "$1,119.00 " "$1,790.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319437 PHYSICIAN FEE - SURGERY PF-HIP ARTHR0 W/SYNOVECTOMY EACH 29863 "$2,235.00 " 960 "$1,564.50 " "$1,117.50 " "$1,788.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319817 PHYSICIAN FEE - SURGERY PF-HIP ARTHRO ACETABULOPLASTY EACH 29915 "$2,793.00 " 960 "$1,955.10 " "$1,396.50 " "$2,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319411 PHYSICIAN FEE - SURGERY PF-HIP ARTHRO W/FB REMOVAL EACH 29861 "$1,637.00 " 960 "$1,145.90 " $818.50 "$1,309.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319809 PHYSICIAN FEE - SURGERY PF-HIP ARTHRO W/FEMOROPLASTY EACH 29914 "$2,722.00 " 960 "$1,905.40 " "$1,361.00 " "$2,177.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319825 PHYSICIAN FEE - SURGERY PF-HIP ARTHRO W/LABRAL REPAIR EACH 29916 "$2,780.00 " 960 "$1,946.00 " "$1,390.00 " "$2,224.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319403 PHYSICIAN FEE - SURGERY PF-HIP ARTHROSCOPY DX EACH 29860 "$1,799.00 " 960 "$1,259.30 " $899.50 "$1,439.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357791 PHYSICIAN FEE - SURGERY PF-HUMERUS OR ELBOW PROC NOS EACH 24999 "$1,613.00 " 960 "$1,129.10 " $806.50 "$1,290.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306483 PHYSICIAN FEE - SURGERY PF-HYOID MYOTOMY & SUSPENSION EACH 21685 "$2,641.00 " 960 "$1,848.70 " "$1,320.50 " "$2,112.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340045 PHYSICIAN FEE - SURGERY PF-HYSTERECTOMY/BLADDER REPAIR EACH 51925 "$2,933.00 " 960 "$2,053.10 " "$1,466.50 " "$2,346.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343999 PHYSICIAN FEE - SURGERY PF-HYSTERECTOMY/REVISE VAGINA EACH 58275 "$2,706.00 " 960 "$1,894.20 " "$1,353.00 " "$2,164.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344005 PHYSICIAN FEE - SURGERY PF-HYSTERECTOMY/REVISE VAGINA EACH 58280 "$2,905.00 " 960 "$2,033.50 " "$1,452.50 " "$2,324.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357882 PHYSICIAN FEE - SURGERY PF-HYSTEROSCOPE PROCEDURE NOS EACH 58579 "$2,723.00 " 960 "$1,906.10 " "$1,361.50 " "$2,178.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344393 PHYSICIAN FEE - SURGERY PF-HYSTEROSCOPY ABLATION EACH 58563 $671.00 960 $469.70 $335.50 $536.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344344 PHYSICIAN FEE - SURGERY PF-HYSTEROSCOPY BIOPSY EACH 58558 $632.00 960 $442.40 $316.00 $505.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344336 PHYSICIAN FEE - SURGERY PF-HYSTEROSCOPY DX SEP PROC EACH 58555 $412.00 960 $288.40 $206.00 $329.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344351 PHYSICIAN FEE - SURGERY PF-HYSTEROSCOPY LYSIS EACH 58559 $776.00 960 $543.20 $388.00 $620.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344385 PHYSICIAN FEE - SURGERY PF-HYSTEROSCOPY REMOVE FB EACH 58562 $606.00 960 $424.20 $303.00 $484.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344377 PHYSICIAN FEE - SURGERY PF-HYSTEROSCOPY REMOVE MYOMA EACH 58561 $980.00 960 $686.00 $490.00 $784.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344369 PHYSICIAN FEE - SURGERY PF-HYSTEROSCOPY RESECT SEPTUM EACH 58560 $856.00 960 $599.20 $428.00 $684.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344401 PHYSICIAN FEE - SURGERY PF-HYSTEROSCOPY STERILIZATION EACH 58565 "$1,249.00 " 960 $874.30 $624.50 $999.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342983 PHYSICIAN FEE - SURGERY PF-I & D VAG HEMATOMA NON-OB EACH 57023 $875.00 960 $612.50 $437.50 $700.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342975 PHYSICIAN FEE - SURGERY PF-I & D VAGINAL HEMATOMA PP EACH 57022 $492.00 960 $344.40 $246.00 $393.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306673 PHYSICIAN FEE - SURGERY PF-I&D P-SPINE C/T/CERV-THOR EACH 22010 "$2,783.00 " 960 "$1,948.10 " "$1,391.50 " "$2,226.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306681 PHYSICIAN FEE - SURGERY PF-I&D P-SPINE L/S/LS EACH 22015 "$2,690.00 " 960 "$1,883.00 " "$1,345.00 " "$2,152.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329899 PHYSICIAN FEE - SURGERY PF-IDENTIFY SENTINEL NODE EACH 38792 $86.00 960 $60.20 $43.00 $68.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334014 PHYSICIAN FEE - SURGERY PF-ILEOSTOMY/JEJUNOSTOMY EACH 44310 "$2,892.00 " 960 "$2,024.40 " "$1,446.00 " "$2,313.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304587 PHYSICIAN FEE - SURGERY PF-ILIAC BONE GRAFT MICROVASC EACH 20956 "$7,258.00 " 960 "$5,080.60 " "$3,629.00 " "$5,806.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337413 PHYSICIAN FEE - SURGERY PF-IMAGE CATH FLUID COLXN VISC EACH 49405 $503.00 960 $352.10 $251.50 $402.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355084 PHYSICIAN FEE - SURGERY PF-IMAGE CATH FLUID TRNS/VGNL EACH 49407 $537.00 960 $375.90 $268.50 $429.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303753 PHYSICIAN FEE - SURGERY PF-IMMEDIATE BREAST PROSTHESIS EACH 19340 "$2,070.00 " 960 "$1,449.00 " "$1,035.00 " "$1,656.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361199 PHYSICIAN FEE - SURGERY PF-IMPL ABSRB MSH/PRSTH DLY CL EACH 15778 "$1,085.00 " 960 $759.50 $542.50 $868.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361504 PHYSICIAN FEE - SURGERY PF-IMPL OI IMPL SK TC ESP>=100 EACH 69729 "$1,805.00 " 960 "$1,263.50 " $902.50 "$1,444.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333461 PHYSICIAN FEE - SURGERY PF-IMPL/REDO ELECTRD ANTRUM EACH 43881 "$3,434.00 " 960 "$2,403.80 " "$1,717.00 " "$2,747.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346307 PHYSICIAN FEE - SURGERY PF-IMPLANT BRAIN ELECTRODES EACH 61531 "$3,678.00 " 960 "$2,574.60 " "$1,839.00 " "$2,942.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346315 PHYSICIAN FEE - SURGERY PF-IMPLANT BRAIN ELECTRODES EACH 61533 "$4,605.00 " 960 "$3,223.50 " "$2,302.50 " "$3,684.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347123 PHYSICIAN FEE - SURGERY PF-IMPLANT BRAIN ELECTRODES EACH 61760 "$4,749.00 " 960 "$3,324.30 " "$2,374.50 " "$3,799.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354335 PHYSICIAN FEE - SURGERY PF-IMPLANT COCHLEAR DEVICE EACH 69930 "$3,252.00 " 960 "$2,276.40 " "$1,626.00 " "$2,601.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351992 PHYSICIAN FEE - SURGERY PF-IMPLANT EYE DRUG SYSTEM EACH 67027 "$2,165.00 " 960 "$1,515.50 " "$1,082.50 " "$1,732.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351562 PHYSICIAN FEE - SURGERY PF-IMPLANT EYE SHUNT EACH 66180 "$2,912.00 " 960 "$2,038.40 " "$1,456.00 " "$2,329.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301179 PHYSICIAN FEE - SURGERY PF-IMPLANT HORMONE PELLET(S) EACH 11980 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350309 PHYSICIAN FEE - SURGERY PF-IMPLANT NERVE END EACH 64787 $636.00 960 $445.20 $318.00 $508.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347271 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRDE ADDL EACH 61864 $856.00 960 $599.20 $428.00 $684.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347297 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRDE ADDL EACH 61868 "$1,514.00 " 960 "$1,059.80 " $757.00 "$1,211.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347263 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODE EACH 61863 "$4,529.00 " 960 "$3,170.30 " "$2,264.50 " "$3,623.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347289 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODE EACH 61867 "$6,889.00 " 960 "$4,822.30 " "$3,444.50 " "$5,511.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347248 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODES EACH 61850 "$2,965.00 " 960 "$2,075.50 " "$1,482.50 " "$2,372.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347255 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODES EACH 61860 "$4,718.00 " 960 "$3,302.60 " "$2,359.00 " "$3,774.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349004 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODES EACH 63655 "$2,441.00 " 960 "$1,708.70 " "$1,220.50 " "$1,952.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349590 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODES EACH 64553 "$1,351.00 " 960 $945.70 $675.50 "$1,080.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349608 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODES EACH 64555 $854.00 960 $597.80 $427.00 $683.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349673 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODES EACH 64575 $850.00 960 $595.00 $425.00 $680.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349681 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODES EACH 64580 $883.00 960 $618.10 $441.50 $706.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349699 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROELECTRODES EACH 64581 "$1,764.00 " 960 "$1,234.80 " $882.00 "$1,411.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347339 PHYSICIAN FEE - SURGERY PF-IMPLANT NEUROSTIM ARRAYS EACH 61886 "$2,585.00 " 960 "$1,809.50 " "$1,292.50 " "$2,068.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347941 PHYSICIAN FEE - SURGERY PF-IMPLANT SPINAL CANAL CATH EACH 62350 "$1,099.00 " 960 $769.30 $549.50 $879.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347958 PHYSICIAN FEE - SURGERY PF-IMPLANT SPINAL CANAL CATH EACH 62351 "$2,673.00 " 960 "$1,871.10 " "$1,336.50 " "$2,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347982 PHYSICIAN FEE - SURGERY PF-IMPLANT SPINE INFUSION PUMP EACH 62361 "$1,282.00 " 960 $897.40 $641.00 "$1,025.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347990 PHYSICIAN FEE - SURGERY PF-IMPLANT SPINE INFUSION PUMP EACH 62362 "$1,079.00 " 960 $755.30 $539.50 $863.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359581 PHYSICIAN FEE - SURGERY PF-IMPLANT TCAT PULM VLV PERQ EACH 33477 "$3,534.00 " 960 "$2,473.80 " "$1,767.00 " "$2,827.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354178 PHYSICIAN FEE - SURGERY PF-IMPLANT TEMPLE BONE W/STIML EACH 69714 "$1,323.00 " 960 $926.10 $661.50 "$1,058.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339187 PHYSICIAN FEE - SURGERY PF-IMPLANT URETER IN BOWEL EACH 50800 "$2,119.00 " 960 "$1,483.30 " "$1,059.50 " "$1,695.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325301 PHYSICIAN FEE - SURGERY PF-IMPLANT VENTRICULAR DEVICE EACH 33976 "$4,398.00 " 960 "$3,078.60 " "$2,199.00 " "$3,518.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325293 PHYSICIAN FEE - SURGERY PF-IMPLANT VENTRICULAR DEVICE EACH 33975 "$3,654.00 " 960 "$2,557.80 " "$1,827.00 " "$2,923.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346216 PHYSICIAN FEE - SURGERY PF-IMPLT BRAIN CHEMOTX ADD-ON EACH 61517 $265.00 960 $185.50 $132.50 $212.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346000 PHYSICIAN FEE - SURGERY PF-IMPLT CRAN BONE FLAP TO ABD EACH 61316 $265.00 960 $185.50 $132.50 $212.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360332 PHYSICIAN FEE - SURGERY PF-IMPLT NTRSTRML CRNL RNG SEG EACH 65785 "$1,134.00 " 960 $793.80 $567.00 $907.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358948 PHYSICIAN FEE - SURGERY PF-IMPLT/RPL CRTD SNS DEV EACH 0266T "$1,088.00 " 960 $761.60 $544.00 $870.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361116 PHYSICIAN FEE - SURGERY PF-IMPLTJ OI IMPLT SKL TC ESP EACH 69716 "$1,660.00 " 960 "$1,162.00 " $830.00 "$1,328.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349640 PHYSICIAN FEE - SURGERY PF-INC FOR VAGUS N ELECT IMPL EACH 64568 "$1,672.00 " 960 "$1,170.40 " $836.00 "$1,337.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339468 PHYSICIAN FEE - SURGERY PF-INCISE & DRAIN BLADDER EACH 51040 $776.00 960 $543.20 $388.00 $620.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339443 PHYSICIAN FEE - SURGERY PF-INCISE & TREAT BLADDER EACH 51020 "$1,253.00 " 960 $877.10 $626.50 "$1,002.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339450 PHYSICIAN FEE - SURGERY PF-INCISE & TREAT BLADDER EACH 51030 "$1,263.00 " 960 $884.10 $631.50 "$1,010.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336415 PHYSICIAN FEE - SURGERY PF-INCISE BILE DUCT SPHINCTER EACH 47460 "$3,595.00 " 960 "$2,516.50 " "$1,797.50 " "$2,876.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339476 PHYSICIAN FEE - SURGERY PF-INCISE BLADDER/DRAIN URETER EACH 51045 "$1,350.00 " 960 $945.00 $675.00 "$1,080.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350168 PHYSICIAN FEE - SURGERY PF-INCISE DIAPHRAGM NERVE EACH 64746 "$1,211.00 " 960 $847.70 $605.50 $968.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335466 PHYSICIAN FEE - SURGERY PF-INCISE EXTERNAL HEMORRHOID EACH 46083 $299.00 960 $209.30 $149.50 $239.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311368 PHYSICIAN FEE - SURGERY PF-INCISE FINGER TENDON SHEATH EACH 26055 $796.00 960 $557.20 $398.00 $636.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309701 PHYSICIAN FEE - SURGERY PF-INCISE FLEXR CARPI RADIALIS EACH 25001 $953.00 960 $667.10 $476.50 $762.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312028 PHYSICIAN FEE - SURGERY PF-INCISE HAND/FINGER TENDON EACH 26460 "$1,205.00 " 960 $843.50 $602.50 $964.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350192 PHYSICIAN FEE - SURGERY PF-INCISE HIP/THIGH NERVE EACH 64763 "$1,454.00 " 960 "$1,017.80 " $727.00 "$1,163.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350200 PHYSICIAN FEE - SURGERY PF-INCISE HIP/THIGH NERVE EACH 64766 "$1,797.00 " 960 "$1,257.90 " $898.50 "$1,437.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354251 PHYSICIAN FEE - SURGERY PF-INCISE INNER EAR EACH 69801 $335.00 960 $234.50 $167.50 $268.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354327 PHYSICIAN FEE - SURGERY PF-INCISE INNER EAR NERVE EACH 69915 "$4,025.00 " 960 "$2,817.50 " "$2,012.50 " "$3,220.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354343 PHYSICIAN FEE - SURGERY PF-INCISE INNER EAR NERVE EACH 69950 "$4,681.00 " 960 "$3,276.70 " "$2,340.50 " "$3,744.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351380 PHYSICIAN FEE - SURGERY PF-INCISE INNER EYE ADHESIONS EACH 65860 $637.00 960 $445.90 $318.50 $509.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351398 PHYSICIAN FEE - SURGERY PF-INCISE INNER EYE ADHESIONS EACH 65865 "$1,223.00 " 960 $856.10 $611.50 $978.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351406 PHYSICIAN FEE - SURGERY PF-INCISE INNER EYE ADHESIONS EACH 65870 "$1,519.00 " 960 "$1,063.30 " $759.50 "$1,215.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351414 PHYSICIAN FEE - SURGERY PF-INCISE INNER EYE ADHESIONS EACH 65875 "$1,622.00 " 960 "$1,135.40 " $811.00 "$1,297.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351422 PHYSICIAN FEE - SURGERY PF-INCISE INNER EYE ADHESIONS EACH 65880 "$1,705.00 " 960 "$1,193.50 " $852.50 "$1,364.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352016 PHYSICIAN FEE - SURGERY PF-INCISE INNER EYE STRANDS EACH 67030 "$1,423.00 " 960 $996.10 $711.50 "$1,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350150 PHYSICIAN FEE - SURGERY PF-INCISE NERVE BACK OF HEAD EACH 64744 "$1,490.00 " 960 "$1,043.00 " $745.00 "$1,192.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346091 PHYSICIAN FEE - SURGERY PF-INCISE SKULL (PRESS RELIEF) EACH 61343 "$6,598.00 " 960 "$4,618.60 " "$3,299.00 " "$5,278.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346125 PHYSICIAN FEE - SURGERY PF-INCISE SKULL BRAIN WOUND EACH 61458 "$6,062.00 " 960 "$4,243.40 " "$3,031.00 " "$4,849.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346562 PHYSICIAN FEE - SURGERY PF-INCISE SKULL BRAIN WOUND EACH 61571 "$6,010.00 " 960 "$4,207.00 " "$3,005.00 " "$4,808.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346117 PHYSICIAN FEE - SURGERY PF-INCISE SKULL FOR SURGERY EACH 61450 "$5,802.00 " 960 "$4,061.40 " "$2,901.00 " "$4,641.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346133 PHYSICIAN FEE - SURGERY PF-INCISE SKULL FOR SURGERY EACH 61460 "$6,358.00 " 960 "$4,450.60 " "$3,179.00 " "$5,086.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347131 PHYSICIAN FEE - SURGERY PF-INCISE SKULL FOR TREATMENT EACH 61770 "$4,899.00 " 960 "$3,429.30 " "$2,449.50 " "$3,919.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347420 PHYSICIAN FEE - SURGERY PF-INCISE SKULL REPAIR EACH 62121 "$4,392.00 " 960 "$3,074.40 " "$2,196.00 " "$3,513.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347107 PHYSICIAN FEE - SURGERY PF-INCISE SKULL/BRAIN BIOPSY EACH 61750 "$4,239.00 " 960 "$2,967.30 " "$2,119.50 " "$3,391.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347081 PHYSICIAN FEE - SURGERY PF-INCISE SKULL/BRAIN SURGERY EACH 61720 "$3,832.00 " 960 "$2,682.40 " "$1,916.00 " "$3,065.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347099 PHYSICIAN FEE - SURGERY PF-INCISE SKULL/BRAIN SURGERY EACH 61735 "$4,811.00 " 960 "$3,367.70 " "$2,405.50 " "$3,848.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346471 PHYSICIAN FEE - SURGERY PF-INCISE SKULL/SUTURES EACH 61556 "$5,152.00 " 960 "$3,606.40 " "$2,576.00 " "$4,121.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346489 PHYSICIAN FEE - SURGERY PF-INCISE SKULL/SUTURES EACH 61557 "$5,077.00 " 960 "$3,553.90 " "$2,538.50 " "$4,061.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342421 PHYSICIAN FEE - SURGERY PF-INCISE SPERM DUCT POUCH EACH 55600 "$1,125.00 " 960 $787.50 $562.50 $900.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342439 PHYSICIAN FEE - SURGERY PF-INCISE SPERM DUCT POUCH EACH 55605 "$1,397.00 " 960 $977.90 $698.50 "$1,117.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348576 PHYSICIAN FEE - SURGERY PF-INCISE SPINAL COLUMN & CORD EACH 63197 "$5,163.00 " 960 "$3,614.10 " "$2,581.50 " "$4,130.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348519 PHYSICIAN FEE - SURGERY PF-INCISE SPINAL COLUMN/NERVES EACH 63185 "$3,689.00 " 960 "$2,582.30 " "$1,844.50 " "$2,951.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348527 PHYSICIAN FEE - SURGERY PF-INCISE SPINAL COLUMN/NERVES EACH 63190 "$3,422.00 " 960 "$2,395.40 " "$1,711.00 " "$2,737.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348535 PHYSICIAN FEE - SURGERY PF-INCISE SPINAL COLUMN/NERVES EACH 63191 "$4,157.00 " 960 "$2,909.90 " "$2,078.50 " "$3,325.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348469 PHYSICIAN FEE - SURGERY PF-INCISE SPINAL CORD TRACT(S) EACH 63170 "$4,802.00 " 960 "$3,361.40 " "$2,401.00 " "$3,841.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353287 PHYSICIAN FEE - SURGERY PF-INCISE TEAR DUCT OPENING EACH 68440 $257.00 960 $179.90 $128.50 $205.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308000 PHYSICIAN FEE - SURGERY PF-INCISE TENDON(S) & MUSC(S) EACH 23406 "$1,976.00 " 960 "$1,383.20 " $988.00 "$1,580.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314255 PHYSICIAN FEE - SURGERY PF-INCISE THIGH TEND & FASCIA EACH 27305 "$1,331.00 " 960 $931.70 $665.50 "$1,064.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310279 PHYSICIAN FEE - SURGERY PF-INCISE WRIST/FOREARM TENDON EACH 25290 "$1,199.00 " 960 $839.30 $599.50 $959.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353089 PHYSICIAN FEE - SURGERY PF-INCISE/DRAIN EYELID LINING EACH 68020 $281.00 960 $196.70 $140.50 $224.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353261 PHYSICIAN FEE - SURGERY PF-INCISE/DRAIN TEAR GLAND EACH 68400 $337.00 960 $235.90 $168.50 $269.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353279 PHYSICIAN FEE - SURGERY PF-INCISE/DRAIN TEAR SAC EACH 68420 $428.00 960 $299.60 $214.00 $342.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317761 PHYSICIAN FEE - SURGERY PF-INCISE/GRAFT MIDFOOT BONES EACH 28305 "$1,815.00 " 960 "$1,270.50 " $907.50 "$1,452.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307721 PHYSICIAN FEE - SURGERY PF-INCISION COLLARBONE JOINT EACH 23106 "$1,386.00 " 960 $970.20 $693.00 "$1,108.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313125 PHYSICIAN FEE - SURGERY PF-INCISION HIP/THIGH FASCIA EACH 27025 "$2,553.00 " 960 "$1,787.10 " "$1,276.50 " "$2,042.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317787 PHYSICIAN FEE - SURGERY PF-INCISION METATAR-1 W/GRAFT EACH 28307 "$1,423.00 " 960 $996.10 $711.50 "$1,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317795 PHYSICIAN FEE - SURGERY PF-INCISION METATARSAL (NOT 1) EACH 28308 "$1,034.00 " 960 $723.80 $517.00 $827.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315625 PHYSICIAN FEE - SURGERY PF-INCISION OF ACHILLES TENDON EACH 27605 $483.00 960 $338.10 $241.50 $386.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315633 PHYSICIAN FEE - SURGERY PF-INCISION OF ACHILLES TENDON EACH 27606 $728.00 960 $509.60 $364.00 $582.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335425 PHYSICIAN FEE - SURGERY PF-INCISION OF ANAL ABSCESS EACH 46050 $276.00 960 $193.20 $138.00 $220.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335441 PHYSICIAN FEE - SURGERY PF-INCISION OF ANAL SEPTUM EACH 46070 $744.00 960 $520.80 $372.00 $595.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335458 PHYSICIAN FEE - SURGERY PF-INCISION OF ANAL SPHINCTER EACH 46080 $435.00 960 $304.50 $217.50 $348.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317746 PHYSICIAN FEE - SURGERY PF-INCISION OF ANKLE BONE EACH 28302 "$1,975.00 " 960 "$1,382.50 " $987.50 "$1,580.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336399 PHYSICIAN FEE - SURGERY PF-INCISION OF BILE DUCT EACH 47420 "$3,780.00 " 960 "$2,646.00 " "$1,890.00 " "$3,024.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336407 PHYSICIAN FEE - SURGERY PF-INCISION OF BILE DUCT EACH 47425 "$3,874.00 " 960 "$2,711.80 " "$1,937.00 " "$3,099.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346398 PHYSICIAN FEE - SURGERY PF-INCISION OF BRAIN TISSUE EACH 61541 "$6,492.00 " 960 "$4,544.40 " "$3,246.00 " "$5,193.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346547 PHYSICIAN FEE - SURGERY PF-INCISION OF BRAIN TISSUE EACH 61567 "$7,709.00 " 960 "$5,396.30 " "$3,854.50 " "$6,167.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303373 PHYSICIAN FEE - SURGERY PF-INCISION OF BREAST LESION EACH 19020 $868.00 960 $607.60 $434.00 $694.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350093 PHYSICIAN FEE - SURGERY PF-INCISION OF BROW NERVE EACH 64732 "$1,332.00 " 960 $932.40 $666.00 "$1,065.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302987 PHYSICIAN FEE - SURGERY PF-INCISION OF BURN SCAB INITI EACH 16035 $533.00 960 $373.10 $266.50 $426.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350101 PHYSICIAN FEE - SURGERY PF-INCISION OF CHEEK NERVE EACH 64734 "$1,504.00 " 960 "$1,052.80 " $752.00 "$1,203.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350119 PHYSICIAN FEE - SURGERY PF-INCISION OF CHIN NERVE EACH 64736 $869.00 960 $608.30 $434.50 $695.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353725 PHYSICIAN FEE - SURGERY PF-INCISION OF EARDRUM EACH 69421 $404.00 960 $282.80 $202.00 $323.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331754 PHYSICIAN FEE - SURGERY PF-INCISION OF ESOPHAGUS EACH 43020 "$1,595.00 " 960 "$1,116.50 " $797.50 "$1,276.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331770 PHYSICIAN FEE - SURGERY PF-INCISION OF ESOPHAGUS EACH 43045 "$3,662.00 " 960 "$2,563.40 " "$1,831.00 " "$2,929.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351364 PHYSICIAN FEE - SURGERY PF-INCISION OF EYE EACH 65850 "$2,156.00 " 960 "$1,509.20 " "$1,078.00 " "$1,724.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352644 PHYSICIAN FEE - SURGERY PF-INCISION OF EYELID EACH 67710 $252.00 960 $176.40 $126.00 $201.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352651 PHYSICIAN FEE - SURGERY PF-INCISION OF EYELID FOLD EACH 67715 $281.00 960 $196.70 $140.50 $224.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350143 PHYSICIAN FEE - SURGERY PF-INCISION OF FACIAL NERVE EACH 64742 "$1,277.00 " 960 $893.90 $638.50 "$1,021.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316144 PHYSICIAN FEE - SURGERY PF-INCISION OF FIBULA EACH 27707 "$1,104.00 " 960 $772.80 $552.00 $883.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311376 PHYSICIAN FEE - SURGERY PF-INCISION OF FINGER TENDON EACH 26060 $696.00 960 $487.20 $348.00 $556.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312010 PHYSICIAN FEE - SURGERY PF-INCISION OF FINGER TENDON EACH 26455 "$1,233.00 " 960 $863.10 $616.50 $986.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316847 PHYSICIAN FEE - SURGERY PF-INCISION OF FOOT FASCIA EACH 28008 $774.00 960 $541.80 $387.00 $619.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317506 PHYSICIAN FEE - SURGERY PF-INCISION OF FOOT TENDON EACH 28234 $712.00 960 $498.40 $356.00 $569.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317480 PHYSICIAN FEE - SURGERY PF-INCISION OF FOOT TENDON(S) EACH 28230 $752.00 960 $526.40 $376.00 $601.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336423 PHYSICIAN FEE - SURGERY PF-INCISION OF GALLBLADDER EACH 47480 "$2,449.00 " 960 "$1,714.30 " "$1,224.50 " "$1,959.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336431 PHYSICIAN FEE - SURGERY PF-INCISION OF GALLBLADDER EACH 47490 $852.00 960 $596.40 $426.00 $681.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322829 PHYSICIAN FEE - SURGERY PF-INCISION OF HEART SAC EACH 33020 "$2,296.00 " 960 "$1,607.20 " "$1,148.00 " "$1,836.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322837 PHYSICIAN FEE - SURGERY PF-INCISION OF HEART SAC EACH 33025 "$2,152.00 " 960 "$1,506.40 " "$1,076.00 " "$1,721.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317738 PHYSICIAN FEE - SURGERY PF-INCISION OF HEEL BONE EACH 28300 "$1,765.00 " 960 "$1,235.50 " $882.50 "$1,412.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313646 PHYSICIAN FEE - SURGERY PF-INCISION OF HIP BONE EACH 27146 "$3,522.00 " 960 "$2,465.40 " "$1,761.00 " "$2,817.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313661 PHYSICIAN FEE - SURGERY PF-INCISION OF HIP BONES EACH 27151 "$4,352.00 " 960 "$3,046.40 " "$2,176.00 " "$3,481.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313075 PHYSICIAN FEE - SURGERY PF-INCISION OF HIP TENDON EACH 27000 "$1,035.00 " 960 $724.50 $517.50 $828.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313083 PHYSICIAN FEE - SURGERY PF-INCISION OF HIP TENDON EACH 27001 "$1,490.00 " 960 "$1,043.00 " $745.00 "$1,192.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313091 PHYSICIAN FEE - SURGERY PF-INCISION OF HIP TENDON EACH 27003 "$1,655.00 " 960 "$1,158.50 " $827.50 "$1,324.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313109 PHYSICIAN FEE - SURGERY PF-INCISION OF HIP TENDON EACH 27005 "$1,655.00 " 960 "$1,158.50 " $827.50 "$1,324.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313117 PHYSICIAN FEE - SURGERY PF-INCISION OF HIP TENDONS EACH 27006 "$1,932.00 " 960 "$1,352.40 " $966.00 "$1,545.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351620 PHYSICIAN FEE - SURGERY PF-INCISION OF IRIS EACH 66500 "$1,007.00 " 960 $704.90 $503.50 $805.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351638 PHYSICIAN FEE - SURGERY PF-INCISION OF IRIS EACH 66505 "$1,095.00 " 960 $766.50 $547.50 $876.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304702 PHYSICIAN FEE - SURGERY PF-INCISION OF JAW JOINT EACH 21010 "$1,940.00 " 960 "$1,358.00 " $970.00 "$1,552.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350127 PHYSICIAN FEE - SURGERY PF-INCISION OF JAW NERVE EACH 64738 "$1,176.00 " 960 $823.20 $588.00 $940.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338171 PHYSICIAN FEE - SURGERY PF-INCISION OF KIDNEY EACH 50065 "$3,198.00 " 960 "$2,238.60 " "$1,599.00 " "$2,558.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338189 PHYSICIAN FEE - SURGERY PF-INCISION OF KIDNEY EACH 50070 "$3,138.00 " 960 "$2,196.60 " "$1,569.00 " "$2,510.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314867 PHYSICIAN FEE - SURGERY PF-INCISION OF KNEE JOINT EACH 27435 "$2,221.00 " 960 "$1,554.70 " "$1,110.50 " "$1,776.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333560 PHYSICIAN FEE - SURGERY PF-INCISION OF LARGE BOWEL EACH 44025 "$2,764.00 " 960 "$1,934.80 " "$1,382.00 " "$2,211.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330236 PHYSICIAN FEE - SURGERY PF-INCISION OF LIP FOLD EACH 40806 $79.00 960 $55.30 $39.50 $63.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336381 PHYSICIAN FEE - SURGERY PF-INCISION OF LIVER DUCT EACH 47400 "$6,104.00 " 960 "$4,272.80 " "$3,052.00 " "$4,883.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329592 PHYSICIAN FEE - SURGERY PF-INCISION OF LYMPH CHANNELS EACH 38308 "$1,313.00 " 960 $919.10 $656.50 "$1,050.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317779 PHYSICIAN FEE - SURGERY PF-INCISION OF METATARSAL-1ST EACH 28306 "$1,094.00 " 960 $765.80 $547.00 $875.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317753 PHYSICIAN FEE - SURGERY PF-INCISION OF MIDFOOT BONES EACH 28304 "$1,657.00 " 960 "$1,159.90 " $828.50 "$1,325.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313695 PHYSICIAN FEE - SURGERY PF-INCISION OF NECK OF FEMUR EACH 27161 "$3,360.00 " 960 "$2,352.00 " "$1,680.00 " "$2,688.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312002 PHYSICIAN FEE - SURGERY PF-INCISION OF PALM TENDON EACH 26450 "$1,241.00 " 960 $868.70 $620.50 $992.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340615 PHYSICIAN FEE - SURGERY PF-INCISION OF PROSTATE EACH 52450 "$1,264.00 " 960 $884.80 $632.00 "$1,011.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332927 PHYSICIAN FEE - SURGERY PF-INCISION OF PYLORIC MUSCLE EACH 43520 "$1,940.00 " 960 "$1,358.00 " $970.00 "$1,552.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335417 PHYSICIAN FEE - SURGERY PF-INCISION OF RECTAL ABSCESS EACH 46045 "$1,205.00 " 960 $843.50 $602.50 $964.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335433 PHYSICIAN FEE - SURGERY PF-INCISION OF RECTAL ABSCESS EACH 46060 "$1,322.00 " 960 $925.40 $661.00 "$1,057.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333529 PHYSICIAN FEE - SURGERY PF-INCISION OF SMALL BOWEL EACH 44010 "$2,322.00 " 960 "$1,625.40 " "$1,161.00 " "$1,857.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342314 PHYSICIAN FEE - SURGERY PF-INCISION OF SPERM DUCT EACH 55200 $739.00 960 $517.30 $369.50 $591.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350226 PHYSICIAN FEE - SURGERY PF-INCISION OF SPINAL NERVE EACH 64772 "$1,532.00 " 960 "$1,072.40 " $766.00 "$1,225.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350176 PHYSICIAN FEE - SURGERY PF-INCISION OF STOMACH NERVES EACH 64755 "$2,617.00 " 960 "$1,831.90 " "$1,308.50 " "$2,093.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307994 PHYSICIAN FEE - SURGERY PF-INCISION OF TENDON & MUSCLE EACH 23405 "$1,682.00 " 960 "$1,177.40 " $841.00 "$1,345.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309693 PHYSICIAN FEE - SURGERY PF-INCISION OF TENDON SHEATH EACH 25000 $946.00 960 $662.20 $473.00 $756.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314966 PHYSICIAN FEE - SURGERY PF-INCISION OF THIGH EACH 27448 "$2,284.00 " 960 "$1,598.80 " "$1,142.00 " "$1,827.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314974 PHYSICIAN FEE - SURGERY PF-INCISION OF THIGH EACH 27450 "$2,773.00 " 960 "$1,941.10 " "$1,386.50 " "$2,218.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314263 PHYSICIAN FEE - SURGERY PF-INCISION OF THIGH TENDON EACH 27306 $912.00 960 $638.40 $456.00 $729.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314610 PHYSICIAN FEE - SURGERY PF-INCISION OF THIGH TENDON EACH 27390 "$1,247.00 " 960 $872.90 $623.50 $997.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314271 PHYSICIAN FEE - SURGERY PF-INCISION OF THIGH TENDONS EACH 27307 "$1,086.00 " 960 $760.20 $543.00 $868.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314628 PHYSICIAN FEE - SURGERY PF-INCISION OF THIGH TENDONS EACH 27391 "$1,598.00 " 960 "$1,118.60 " $799.00 "$1,278.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314636 PHYSICIAN FEE - SURGERY PF-INCISION OF THIGH TENDONS EACH 27392 "$1,644.00 " 960 "$1,150.80 " $822.00 "$1,315.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316136 PHYSICIAN FEE - SURGERY PF-INCISION OF TIBIA EACH 27705 "$2,049.00 " 960 "$1,434.30 " "$1,024.50 " "$1,639.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316151 PHYSICIAN FEE - SURGERY PF-INCISION OF TIBIA & FIBULA EACH 27709 "$3,141.00 " 960 "$2,198.70 " "$1,570.50 " "$2,512.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316854 PHYSICIAN FEE - SURGERY PF-INCISION OF TOE TENDON EACH 28010 $546.00 960 $382.20 $273.00 $436.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316862 PHYSICIAN FEE - SURGERY PF-INCISION OF TOE TENDONS EACH 28011 $736.00 960 $515.20 $368.00 $588.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330459 PHYSICIAN FEE - SURGERY PF-INCISION OF TONGUE FOLD EACH 41010 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350135 PHYSICIAN FEE - SURGERY PF-INCISION OF TONGUE NERVE EACH 64740 "$1,198.00 " 960 $838.60 $599.00 $958.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340722 PHYSICIAN FEE - SURGERY PF-INCISION OF URETHRA EACH 53020 $256.00 960 $179.20 $128.00 $204.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340706 PHYSICIAN FEE - SURGERY PF-INCISION OF URETHRA EACH 53000 $395.00 960 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340714 PHYSICIAN FEE - SURGERY PF-INCISION OF URETHRA EACH 53010 $791.00 960 $553.70 $395.50 $632.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350184 PHYSICIAN FEE - SURGERY PF-INCISION OF VAGUS NERVE EACH 64760 "$1,470.00 " 960 "$1,029.00 " $735.00 "$1,176.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321250 PHYSICIAN FEE - SURGERY PF-INCISION OF WINDPIPE EACH 31600 $841.00 960 $588.70 $420.50 $672.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321268 PHYSICIAN FEE - SURGERY PF-INCISION OF WINDPIPE EACH 31601 "$1,209.00 " 960 $846.30 $604.50 $967.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321276 PHYSICIAN FEE - SURGERY PF-INCISION OF WINDPIPE EACH 31603 $880.00 960 $616.00 $440.00 $704.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321284 PHYSICIAN FEE - SURGERY PF-INCISION OF WINDPIPE EACH 31605 $915.00 960 $640.50 $457.50 $732.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321292 PHYSICIAN FEE - SURGERY PF-INCISION OF WINDPIPE EACH 31610 "$2,547.00 " 960 "$1,782.90 " "$1,273.50 " "$2,037.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309875 PHYSICIAN FEE - SURGERY PF-INCISION OF WRIST CAPSULE EACH 25085 "$1,234.00 " 960 $863.80 $617.00 $987.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351794 PHYSICIAN FEE - SURGERY PF-INCISION SECONDARY CATARACT EACH 66820 "$1,194.00 " 960 $835.80 $597.00 $955.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317498 PHYSICIAN FEE - SURGERY "PF-INCISION TOE TENDON, SINGLE" EACH 28232 $635.00 960 $444.50 $317.50 $508.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313703 PHYSICIAN FEE - SURGERY PF-INCISION/FIXATION OF FEMUR EACH 27165 "$3,771.00 " 960 "$2,639.70 " "$1,885.50 " "$3,016.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358351 PHYSICIAN FEE - SURGERY PF-INCISIONAL SKIN BIOPSY 1ST EACH 11106 $150.00 960 $105.00 $75.00 $120.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358369 PHYSICIAN FEE - SURGERY PF-INCISIONAL SKIN BIOPSY ADDL EACH 11107 $82.00 960 $57.40 $41.00 $65.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346661 PHYSICIAN FEE - SURGERY PF-INFRATEMPORL APPROACH/SKULL EACH 61590 "$8,281.00 " 960 "$5,796.70 " "$4,140.50 " "$6,624.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346679 PHYSICIAN FEE - SURGERY PF-INFRATEMPORL APPROACH/SKULL EACH 61591 "$8,527.00 " 960 "$5,968.90 " "$4,263.50 " "$6,821.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356496 PHYSICIAN FEE - SURGERY PF-INJ ANES GANGLION SPHENO BI EACH 64505 $294.00 960 $205.80 $147.00 $235.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356223 PHYSICIAN FEE - SURGERY PF-INJ ANES LUMBAR/THORACIC BI EACH 64520 $222.00 960 $155.40 $111.00 $177.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355449 PHYSICIAN FEE - SURGERY PF-INJ ANES/STER C/T ADD BI EACH 64491 $156.00 960 $109.20 $78.00 $124.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355423 PHYSICIAN FEE - SURGERY PF-INJ ANES/STER C/T ADD RT EACH 64491 $156.00 960 $109.20 $78.00 $124.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355415 PHYSICIAN FEE - SURGERY PF-INJ ANES/STER C/T SGL BI EACH 64490 $276.00 960 $193.20 $138.00 $220.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355399 PHYSICIAN FEE - SURGERY PF-INJ ANES/STER C/T SGL RT EACH 64490 $276.00 960 $193.20 $138.00 $220.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355530 PHYSICIAN FEE - SURGERY PF-INJ ANES/STER L/S ADD BI EACH 64494 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355506 PHYSICIAN FEE - SURGERY PF-INJ ANES/STER L/S SGL BI EACH 64493 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351463 PHYSICIAN FEE - SURGERY PF-INJ ANT CHAMBER EYE AIR/LIQ EACH 66020 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356256 PHYSICIAN FEE - SURGERY PF-INJ CARPAL TUNNEL THERAP BI EACH 20526 $155.00 960 $108.50 $77.50 $124.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356249 PHYSICIAN FEE - SURGERY PF-INJ CARPAL TUNNEL THERAP LT EACH 20526 $155.00 960 $108.50 $77.50 $124.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356231 PHYSICIAN FEE - SURGERY PF-INJ CARPAL TUNNEL THERAP RT EACH 20526 $155.00 960 $108.50 $77.50 $124.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304108 PHYSICIAN FEE - SURGERY PF-INJ DUPUYTREN CORD W/ENZYME EACH 20527 $180.00 960 $126.00 $90.00 $144.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355217 PHYSICIAN FEE - SURGERY PF-INJ EPID W/US CER/THR ADD EACH 0229T $190.00 960 $133.00 $95.00 $152.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355209 PHYSICIAN FEE - SURGERY PF-INJ EPID W/US CER/THR SGL EACH 0228T $314.00 960 $219.80 $157.00 $251.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355233 PHYSICIAN FEE - SURGERY PF-INJ EPID W/US LUMB/SC ADD EACH 0231T $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355225 PHYSICIAN FEE - SURGERY PF-INJ EPID W/US LUMB/SC SGL EACH 0230T $147.00 960 $102.90 $73.50 $117.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355274 PHYSICIAN FEE - SURGERY PF-INJ EPIDUR CERV/THOR SGL RT EACH 64479 $340.00 960 $238.00 $170.00 $272.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331341 PHYSICIAN FEE - SURGERY PF-INJ FOR SALIVARY X-RAY EACH 42550 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357387 PHYSICIAN FEE - SURGERY PF-INJ FOR SHOULDER X-RAY BI EACH 23350 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357379 PHYSICIAN FEE - SURGERY PF-INJ FOR SHOULDER X-RAY LT EACH 23350 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357361 PHYSICIAN FEE - SURGERY PF-INJ FOR SHOULDER X-RAY RT EACH 23350 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355357 PHYSICIAN FEE - SURGERY PF-INJ FORAMEN EPIDUR L/S BI EACH 64483 $291.00 960 $203.70 $145.50 $232.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358708 PHYSICIAN FEE - SURGERY PF-INJ INTERLAMINAR LMBR/SAC EACH 36483 $247.00 960 $172.90 $123.50 $197.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335649 PHYSICIAN FEE - SURGERY PF-INJ INTO HEMORRHOID(S) EACH 46500 $483.00 960 $338.10 $241.50 $386.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358765 PHYSICIAN FEE - SURGERY PF-INJ NEPH/URETERO NEW ACC EACH 55874 $430.00 960 $301.00 $215.00 $344.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355563 PHYSICIAN FEE - SURGERY PF-INJ PARA F JNT L/S LEV3 BI EACH 64495 $136.00 960 $95.20 $68.00 $108.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355472 PHYSICIAN FEE - SURGERY PF-INJ PARAV F JNT C/T LEV3 BI EACH 64492 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355142 PHYSICIAN FEE - SURGERY PF-INJ PARAVERT W/US CER/THR S EACH 0213T $536.00 960 $375.20 $268.00 $428.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355183 PHYSICIAN FEE - SURGERY PF-INJ PARAVERT W/US LUMB/SC 2 EACH 0217T $251.00 960 $175.70 $125.50 $200.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355191 PHYSICIAN FEE - SURGERY PF-INJ PARAVERT W/US LUMB/SC 3 EACH 0218T $251.00 960 $175.70 $125.50 $200.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355159 PHYSICIAN FEE - SURGERY PF-INJ PARAVT W/US CER/THR 2D EACH 0214T $270.00 960 $189.00 $135.00 $216.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355175 PHYSICIAN FEE - SURGERY PF-INJ PARAVT W/US LUMB/SC SGL EACH 0216T $486.00 960 $340.20 $243.00 $388.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355597 PHYSICIAN FEE - SURGERY PF-INJ SGL TENDON/LIGAMENT BI EACH 20550 $105.00 960 $73.50 $52.50 $84.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355589 PHYSICIAN FEE - SURGERY PF-INJ SGL TENDON/LIGAMENT LT EACH 20550 $105.00 960 $73.50 $52.50 $84.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355571 PHYSICIAN FEE - SURGERY PF-INJ SGL TENDON/LIGAMENT RT EACH 20550 $105.00 960 $73.50 $52.50 $84.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304066 PHYSICIAN FEE - SURGERY PF-INJ SINUS TRACT FOR X-RAY EACH 20501 $95.00 960 $66.50 $47.50 $76.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347933 PHYSICIAN FEE - SURGERY PF-INJ SPINE W/CATH L/S (CD) EACH 62327 $282.00 960 $197.40 $141.00 $225.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304132 PHYSICIAN FEE - SURGERY PF-INJ TRIGGER POINT 1/2 MUSCL EACH 20552 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328412 PHYSICIAN FEE - SURGERY PF-INJ W/FLUOR EVAL CV DEVICE EACH 36598 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347842 PHYSICIAN FEE - SURGERY PF-INJECT FOR SPINE DISK X-RAY EACH 62291 $370.00 960 $259.00 $185.00 $296.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347917 PHYSICIAN FEE - SURGERY PF-INJECT SPINE L/S (CD) EACH 62323 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347925 PHYSICIAN FEE - SURGERY PF-INJECT SPINE W/CATH C/T EACH 62325 $289.00 960 $202.30 $144.50 $231.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304140 PHYSICIAN FEE - SURGERY PF-INJECT TRIGGER POINTS =/> 3 EACH 20553 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336126 PHYSICIAN FEE - SURGERY PF-INJECT/ASPIRATE LIVER CYST EACH 47015 "$3,293.00 " 960 "$2,305.10 " "$1,646.50 " "$2,634.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337538 PHYSICIAN FEE - SURGERY PF-INJECTION ABDOMINAL SHUNT EACH 49427 $104.00 960 $72.80 $52.00 $83.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339716 PHYSICIAN FEE - SURGERY PF-INJECTION FOR BLADDER X-RAY EACH 51600 $114.00 960 $79.80 $57.00 $91.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303381 PHYSICIAN FEE - SURGERY PF-INJECTION FOR BREAST X-RAY EACH 19030 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358609 PHYSICIAN FEE - SURGERY PF-INJECTION FOR CHOLANGIOGRAM EACH 34710 "$2,228.00 " 960 "$1,559.60 " "$1,114.00 " "$1,782.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308935 PHYSICIAN FEE - SURGERY PF-INJECTION FOR ELBOW X-RAY EACH 24220 $173.00 960 $121.10 $86.50 $138.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313471 PHYSICIAN FEE - SURGERY PF-INJECTION FOR HIP X-RAY EACH 27095 $220.00 960 $154.00 $110.00 $176.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357411 PHYSICIAN FEE - SURGERY PF-INJECTION FOR HIP X-RAY BI EACH 27093 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357403 PHYSICIAN FEE - SURGERY PF-INJECTION FOR HIP X-RAY LT EACH 27093 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357395 PHYSICIAN FEE - SURGERY PF-INJECTION FOR HIP X-RAY RT EACH 27093 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329469 PHYSICIAN FEE - SURGERY PF-INJECTION FOR SPLEEN X-RAY EACH 38200 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339005 PHYSICIAN FEE - SURGERY PF-INJECTION FOR URETER X-RAY EACH 50684 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339039 PHYSICIAN FEE - SURGERY PF-INJECTION FOR URETER X-RAY EACH 50690 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310147 PHYSICIAN FEE - SURGERY PF-INJECTION FOR WRIST X-RAY EACH 25246 $192.00 960 $134.40 $96.00 $153.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345770 PHYSICIAN FEE - SURGERY PF-INJECTION INTO BRAIN CANAL EACH 61026 $313.00 960 $219.10 $156.50 $250.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320930 PHYSICIAN FEE - SURGERY PF-INJECTION INTO VOCAL CORD EACH 31513 $352.00 960 $246.40 $176.00 $281.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337017 PHYSICIAN FEE - SURGERY PF-INJECTION INTRAOP ADD-ON EACH 48400 $302.00 960 $211.40 $151.00 $241.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305089 PHYSICIAN FEE - SURGERY PF-INJECTION JAW JOINT X-RAY EACH 21116 $116.00 960 $81.20 $58.00 $92.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304058 PHYSICIAN FEE - SURGERY PF-INJECTION OF SINUS TRACT EACH 20500 $236.00 960 $165.20 $118.00 $188.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327968 PHYSICIAN FEE - SURGERY PF-INJECTION THERAPY OF VEINS EACH 36471 $210.00 960 $147.00 $105.00 $168.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349749 PHYSICIAN FEE - SURGERY PF-INJECTION TREATMENT NERVE EACH 64605 "$1,266.00 " 960 $886.20 $633.00 "$1,012.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349756 PHYSICIAN FEE - SURGERY PF-INJECTION TREATMENT NERVE EACH 64610 "$1,398.00 " 960 $978.60 $699.00 "$1,118.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349806 PHYSICIAN FEE - SURGERY PF-INJECTION TREATMENT NERVE EACH 64620 $470.00 960 $329.00 $235.00 $376.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319973 PHYSICIAN FEE - SURGERY PF-INJECTION TREATMENT OF NOSE EACH 30200 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327943 PHYSICIAN FEE - SURGERY PF-INJECTION(S) SPIDER VEINS EACH 36468 $261.00 960 $182.70 $130.50 $208.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347024 PHYSICIAN FEE - SURGERY PF-INNER SKULL VESSEL SURGERY EACH 61702 "$12,149.00 " 960 "$8,504.30 " "$6,074.50 " "$9,719.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327778 PHYSICIAN FEE - SURGERY PF-INS CATH REN ART 1ST BILAT EACH 36252 $986.00 960 $690.20 $493.00 $788.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327794 PHYSICIAN FEE - SURGERY PF-INS CATH REN ART 2ND+ BILAT EACH 36254 "$1,149.00 " 960 $804.30 $574.50 $919.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327786 PHYSICIAN FEE - SURGERY PF-INS CATH REN ART 2ND+ UNI EACH 36253 $924.00 960 $646.80 $462.00 $739.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337447 PHYSICIAN FEE - SURGERY PF-INS DEV FOR RT GUIDE OPEN EACH 49412 $235.00 960 $164.50 $117.50 $188.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301187 PHYSICIAN FEE - SURGERY PF-INS IMPL DRUG DELIV NON-BIO EACH 11981 $173.00 960 $121.10 $86.50 $138.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358823 PHYSICIAN FEE - SURGERY PF-INS INTERBODY BIOMECH DEV EACH 22853 $749.00 960 $524.30 $374.50 $599.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337439 PHYSICIAN FEE - SURGERY PF-INS MARK ABD/PEL RT PERQ EACH 49411 $479.00 960 $335.30 $239.50 $383.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322241 PHYSICIAN FEE - SURGERY PF-INS MARK THOR FOR RT PERQ EACH 32553 $455.00 960 $318.50 $227.50 $364.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337470 PHYSICIAN FEE - SURGERY PF-INS TUN IP CATH DIAL OPN EACH 49421 $641.00 960 $448.70 $320.50 $512.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343148 PHYSICIAN FEE - SURGERY PF-INS VAG BRACHYTX DEVICE EACH 57156 $393.00 960 $275.10 $196.50 $314.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358831 PHYSICIAN FEE - SURGERY PF-INS VERTEBRAL BIOMECH DEV EACH 22854 $982.00 960 $687.40 $491.00 $785.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358849 PHYSICIAN FEE - SURGERY PF-INS VERTEBRAL BIOMECH DEV + EACH 22859 $969.00 960 $678.30 $484.50 $775.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354616 PHYSICIAN FEE - SURGERY PF-INS/REP SUBQ DEFIBRILLATOR EACH 33270 "$1,538.00 " 960 "$1,076.60 " $769.00 "$1,230.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323025 PHYSICIAN FEE - SURGERY PF-INSERT 1 ELECTRODE PM-DEFIB EACH 33216 "$1,016.00 " 960 $711.20 $508.00 $812.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323033 PHYSICIAN FEE - SURGERY PF-INSERT 2 ELECTRODE PM-DEFIB EACH 33217 "$1,009.00 " 960 $706.30 $504.50 $807.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337512 PHYSICIAN FEE - SURGERY PF-INSERT ABDOMEN-VENOUS DRAIN EACH 49425 "$2,212.00 " 960 "$1,548.40 " "$1,106.00 " "$1,769.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304223 PHYSICIAN FEE - SURGERY PF-INSERT AND REMOVE BONE PIN EACH 20650 $451.00 960 $315.70 $225.50 $360.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325277 PHYSICIAN FEE - SURGERY PF-INSERT BALLOON DEVICE EACH 33973 "$1,392.00 " 960 $974.40 $696.00 "$1,113.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345911 PHYSICIAN FEE - SURGERY PF-INSERT BRAIN-FLUID DEVICE EACH 61215 "$1,522.00 " 960 "$1,065.40 " $761.00 "$1,217.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322274 PHYSICIAN FEE - SURGERY PF-INSERT CATH PLEURA WO IMAGE EACH 32556 $334.00 960 $233.80 $167.00 $267.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325053 PHYSICIAN FEE - SURGERY PF-INSERT ENDOVASC PROSTH TAA EACH 33883 "$3,113.00 " 960 "$2,179.10 " "$1,556.50 " "$2,490.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322928 PHYSICIAN FEE - SURGERY PF-INSERT EPICARD ELTRD ENDO EACH 33203 "$2,271.00 " 960 "$1,589.70 " "$1,135.50 " "$1,816.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322910 PHYSICIAN FEE - SURGERY PF-INSERT EPICARD ELTRD OPEN EACH 33202 "$2,152.00 " 960 "$1,506.40 " "$1,076.00 " "$1,721.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352602 PHYSICIAN FEE - SURGERY PF-INSERT EYE SOCKET IMPLANT EACH 67550 "$2,774.00 " 960 "$1,941.80 " "$1,387.00 " "$2,219.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344146 PHYSICIAN FEE - SURGERY PF-INSERT HEYMAN UTERI CAPSULE EACH 58346 "$1,291.00 " 960 $903.70 $645.50 "$1,032.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325236 PHYSICIAN FEE - SURGERY PF-INSERT IA PERCUT DEVICE EACH 33967 $718.00 960 $502.60 $359.00 $574.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325335 PHYSICIAN FEE - SURGERY PF-INSERT INTRACORPOREAL DEV EACH 33979 "$3,974.00 " 960 "$2,781.80 " "$1,987.00 " "$3,179.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344070 PHYSICIAN FEE - SURGERY PF-INSERT INTRAUTERINE DEVICE EACH 58300 $133.00 960 $93.10 $66.50 $106.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351927 PHYSICIAN FEE - SURGERY PF-INSERT LENS PROSTHESIS EACH 66985 "$1,964.00 " 960 "$1,374.80 " $982.00 "$1,571.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323512 PHYSICIAN FEE - SURGERY PF-INSERT MAJOR VESSEL GRAFT EACH 33330 "$3,949.00 " 960 "$2,764.30 " "$1,974.50 " "$3,159.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323520 PHYSICIAN FEE - SURGERY PF-INSERT MAJOR VESSEL GRAFT EACH 33335 "$5,181.00 " 960 "$3,626.70 " "$2,590.50 " "$4,144.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343262 PHYSICIAN FEE - SURGERY PF-INSERT MESH/PELVC FLR ADDON EACH 57267 $680.00 960 $476.00 $340.00 $544.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341811 PHYSICIAN FEE - SURGERY PF-INSERT MULTI-CMP PENIS PROS EACH 54405 "$2,145.00 " 960 "$1,501.50 " "$1,072.50 " "$1,716.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319999 PHYSICIAN FEE - SURGERY PF-INSERT NASAL SEPTAL BUTTON EACH 30220 $343.00 960 $240.10 $171.50 $274.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328479 PHYSICIAN FEE - SURGERY PF-INSERT NEEDLE BONE CAVITY EACH 36680 $165.00 960 $115.50 $82.50 $132.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333537 PHYSICIAN FEE - SURGERY PF-INSERT NEEDLE CATH BOWEL EACH 44015 $400.00 960 $280.00 $200.00 $320.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328115 PHYSICIAN FEE - SURGERY PF-INSERT NON-TUNNEL CV CATH EACH 36555 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350887 PHYSICIAN FEE - SURGERY PF-INSERT OCULAR IMPLANT EACH 65130 "$2,183.00 " 960 "$1,528.10 " "$1,091.50 " "$1,746.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350895 PHYSICIAN FEE - SURGERY PF-INSERT OCULAR IMPLANT EACH 65135 "$2,209.00 " 960 "$1,546.30 " "$1,104.50 " "$1,767.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323090 PHYSICIAN FEE - SURGERY PF-INSERT PACING LEAD&CONNECT EACH 33224 "$1,411.00 " 960 $987.70 $705.50 "$1,128.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307366 PHYSICIAN FEE - SURGERY PF-INSERT PELV FIXATION DEVICE EACH 22848 "$1,034.00 " 960 $723.80 $517.00 $827.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343155 PHYSICIAN FEE - SURGERY PF-INSERT PESSARY/OTHER DEVICE EACH 57160 $125.00 960 $87.50 $62.50 $100.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328206 PHYSICIAN FEE - SURGERY PF-INSERT PICC CATH EACH 36568 $244.00 960 $170.80 $122.00 $195.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328214 PHYSICIAN FEE - SURGERY PF-INSERT PICC CATH EACH 36569 $255.00 960 $178.50 $127.50 $204.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328230 PHYSICIAN FEE - SURGERY PF-INSERT PICVAD CATH EACH 36571 $858.00 960 $600.60 $429.00 $686.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322217 PHYSICIAN FEE - SURGERY PF-INSERT PLEURAL CATH EACH 32550 $542.00 960 $379.40 $271.00 $433.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341241 PHYSICIAN FEE - SURGERY PF-INSERT PROST URETHRAL STENT EACH 53855 $217.00 960 $151.90 $108.50 $173.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323066 PHYSICIAN FEE - SURGERY PF-INSERT PULSE GEN MULT LEADS EACH 33221 $979.00 960 $685.30 $489.50 $783.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323231 PHYSICIAN FEE - SURGERY PF-INSERT PULSE GENERATOR EACH 33240 "$1,012.00 " 960 $708.40 $506.00 $809.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322985 PHYSICIAN FEE - SURGERY PF-INSERT PULSE GENERATOR EACH 33212 $887.00 960 $620.90 $443.50 $709.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322993 PHYSICIAN FEE - SURGERY PF-INSERT PULSE GENERATOR EACH 33213 $930.00 960 $651.00 $465.00 $744.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341803 PHYSICIAN FEE - SURGERY PF-INSERT SELF-CONTD PROSTHES EACH 54401 "$1,766.00 " 960 "$1,236.20 " $883.00 "$1,412.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341795 PHYSICIAN FEE - SURGERY PF-INSERT SEMI-RIGID PROSTHES EACH 54400 "$1,417.00 " 960 $991.90 $708.50 "$1,133.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307291 PHYSICIAN FEE - SURGERY PF-INSERT SPINE FIXATION DEV EACH 22840 "$2,190.00 " 960 "$1,533.00 " "$1,095.00 " "$1,752.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307309 PHYSICIAN FEE - SURGERY PF-INSERT SPINE FIXATION DEV EACH 22842 "$2,221.00 " 960 "$1,554.70 " "$1,110.50 " "$1,776.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307317 PHYSICIAN FEE - SURGERY PF-INSERT SPINE FIXATION DEV EACH 22843 "$2,380.00 " 960 "$1,666.00 " "$1,190.00 " "$1,904.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307325 PHYSICIAN FEE - SURGERY PF-INSERT SPINE FIXATION DEV EACH 22844 "$2,819.00 " 960 "$1,973.30 " "$1,409.50 " "$2,255.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307333 PHYSICIAN FEE - SURGERY PF-INSERT SPINE FIXATION DEV EACH 22845 "$2,120.00 " 960 "$1,484.00 " "$1,060.00 " "$1,696.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307341 PHYSICIAN FEE - SURGERY PF-INSERT SPINE FIXATION DEV EACH 22846 "$2,209.00 " 960 "$1,546.30 " "$1,104.50 " "$1,767.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307358 PHYSICIAN FEE - SURGERY PF-INSERT SPINE FIXATION DEV EACH 22847 "$2,200.00 " 960 "$1,540.00 " "$1,100.00 " "$1,760.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358666 PHYSICIAN FEE - SURGERY PF-INSERT SPINE FIXATION DEV EACH 34716 "$1,041.00 " 960 $728.70 $520.50 $832.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347974 PHYSICIAN FEE - SURGERY PF-INSERT SPINE INFUSION DEV EACH 62360 $863.00 960 $604.10 $431.50 $690.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337561 PHYSICIAN FEE - SURGERY PF-INSERT SUBQ EXTEN IP CATH EACH 49435 $335.00 960 $234.50 $167.50 $268.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341001 PHYSICIAN FEE - SURGERY PF-INSERT TANDEM CUFF EACH 53444 "$2,106.00 " 960 "$1,474.20 " "$1,053.00 " "$1,684.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339765 PHYSICIAN FEE - SURGERY PF-INSERT TEMP BLADDER CATH EACH 51702 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301138 PHYSICIAN FEE - SURGERY PF-INSERT TISSUE EXPANDER(S) EACH 11960 "$2,712.00 " 960 "$1,898.40 " "$1,356.00 " "$2,169.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337462 PHYSICIAN FEE - SURGERY PF-INSERT TUN IP CATH W/PORT EACH 49419 "$1,162.00 " 960 $813.40 $581.00 $929.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328131 PHYSICIAN FEE - SURGERY PF-INSERT TUNNELED CV CATH EACH 36557 $900.00 960 $630.00 $450.00 $720.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328156 PHYSICIAN FEE - SURGERY PF-INSERT TUNNELED CV CATH EACH 36560 "$1,079.00 " 960 $755.30 $539.50 $863.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328172 PHYSICIAN FEE - SURGERY PF-INSERT TUNNELED CV CATH EACH 36563 $991.00 960 $693.70 $495.50 $792.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328180 PHYSICIAN FEE - SURGERY PF-INSERT TUNNELED CV CATH EACH 36565 $930.00 960 $651.00 $465.00 $744.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328198 PHYSICIAN FEE - SURGERY PF-INSERT TUNNELED CV CATH EACH 36566 $967.00 960 $676.90 $483.50 $773.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338940 PHYSICIAN FEE - SURGERY PF-INSERT URETERAL SUPPORT EACH 50605 "$2,824.00 " 960 "$1,976.80 " "$1,412.00 " "$2,259.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341019 PHYSICIAN FEE - SURGERY PF-INSERT URO/VES NCK SPHINCTR EACH 53445 "$2,011.00 " 960 "$1,407.70 " "$1,005.50 " "$1,608.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343130 PHYSICIAN FEE - SURGERY PF-INSERT UTERI TANDEMS/OVOIDS EACH 57155 $741.00 960 $518.70 $370.50 $592.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325392 PHYSICIAN FEE - SURGERY PF-INSERT VAD ART&VEIN ACCESS EACH 33991 "$1,264.00 " 960 $884.80 $632.00 "$1,011.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325384 PHYSICIAN FEE - SURGERY PF-INSERT VAD ARTERY ACCESS EACH 33990 "$1,001.00 " 960 $700.70 $500.50 $800.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328438 PHYSICIAN FEE - SURGERY PF-INSERTION CATHETER ARTERY EACH 36620 $115.00 960 $80.50 $57.50 $92.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328446 PHYSICIAN FEE - SURGERY PF-INSERTION CATHETER ARTERY EACH 36625 $284.00 960 $198.80 $142.00 $227.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328453 PHYSICIAN FEE - SURGERY PF-INSERTION CATHETER ARTERY EACH 36640 $304.00 960 $212.80 $152.00 $243.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328461 PHYSICIAN FEE - SURGERY PF-INSERTION CATHETER ARTERY EACH 36660 $175.00 960 $122.50 $87.50 $140.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322977 PHYSICIAN FEE - SURGERY PF-INSERTION HEART ELECTRODE EACH 33211 $465.00 960 $325.50 $232.50 $372.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322969 PHYSICIAN FEE - SURGERY PF-INSERTION HEART ELECTRODE EACH 33210 $443.00 960 $310.10 $221.50 $354.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322936 PHYSICIAN FEE - SURGERY PF-INSERTION HEART PACEMAKER EACH 33206 "$1,245.00 " 960 $871.50 $622.50 $996.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322944 PHYSICIAN FEE - SURGERY PF-INSERTION HEART PACEMAKER EACH 33207 "$1,314.00 " 960 $919.80 $657.00 "$1,051.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322951 PHYSICIAN FEE - SURGERY PF-INSERTION HEART PACEMAKER EACH 33208 "$1,424.00 " 960 $996.80 $712.00 "$1,139.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354913 PHYSICIAN FEE - SURGERY PF-INSERTION LEFT HEART VENT EACH 33988 "$2,154.00 " 960 "$1,507.80 " "$1,077.00 " "$1,723.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328487 PHYSICIAN FEE - SURGERY PF-INSERTION OF CANNULA EACH 36800 $319.00 960 $223.30 $159.50 $255.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328495 PHYSICIAN FEE - SURGERY PF-INSERTION OF CANNULA EACH 36810 $547.00 960 $382.90 $273.50 $437.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328503 PHYSICIAN FEE - SURGERY PF-INSERTION OF CANNULA EACH 36815 $382.00 960 $267.40 $191.00 $305.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328552 PHYSICIAN FEE - SURGERY PF-INSERTION OF CANNULA(S) EACH 36823 "$3,977.00 " 960 "$2,783.90 " "$1,988.50 " "$3,181.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328016 PHYSICIAN FEE - SURGERY PF-INSERTION OF CATHETER VEIN EACH 36481 $845.00 960 $591.50 $422.50 $676.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328024 PHYSICIAN FEE - SURGERY PF-INSERTION OF CATHETER VEIN EACH 36500 $497.00 960 $347.90 $248.50 $397.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328032 PHYSICIAN FEE - SURGERY PF-INSERTION OF CATHETER VEIN EACH 36510 $137.00 960 $95.90 $68.50 $109.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327802 PHYSICIAN FEE - SURGERY PF-INSERTION OF INFUSION PUMP EACH 36260 "$1,852.00 " 960 "$1,296.40 " $926.00 "$1,481.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331101 PHYSICIAN FEE - SURGERY PF-INSERTION PALATE PROSTHESIS EACH 42281 $420.00 960 $294.00 $210.00 $336.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360902 PHYSICIAN FEE - SURGERY PF-INSJ ANT SGM AQ DRG DEV 1+ EACH 0671T "$1,550.00 " 960 "$1,085.00 " $775.00 "$1,240.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359623 PHYSICIAN FEE - SURGERY PF-INSJ PICC RS&I <5 YR EACH 36572 $216.00 960 $151.20 $108.00 $172.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358971 PHYSICIAN FEE - SURGERY PF-INSJ PICC RS&I 5 YR+ EACH 36573 $216.00 960 $151.20 $108.00 $172.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361108 PHYSICIAN FEE - SURGERY PF-INSJ RX ELUT IMPL LAC CANAL EACH 68841 $83.00 960 $58.10 $41.50 $66.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359359 PHYSICIAN FEE - SURGERY PF-INSJ STABLJ DEV W/DCMPRN EACH 22867 "$3,084.00 " 960 "$2,158.80 " "$1,542.00 " "$2,467.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359367 PHYSICIAN FEE - SURGERY PF-INSJ STABLJ DEV W/DCMPRN EACH 22868 $707.00 960 $494.90 $353.50 $565.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359375 PHYSICIAN FEE - SURGERY PF-INSJ STABLJ DEV W/O DCMPRN EACH 22869 "$1,138.00 " 960 $796.60 $569.00 $910.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359383 PHYSICIAN FEE - SURGERY PF-INSJ STABLJ DEV W/O DCMPRN EACH 22870 $308.00 960 $215.60 $154.00 $246.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359524 PHYSICIAN FEE - SURGERY PF-INSJ SUBQ CAR RHYTHM MNTR EACH 33285 $242.00 960 $169.40 $121.00 $193.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354624 PHYSICIAN FEE - SURGERY PF-INSJ SUBQ IMPLTBL DFB ELCTR EACH 33271 "$1,255.00 " 960 $878.50 $627.50 "$1,004.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502371 PHYSICIAN FEE - SURGERY PF-INSJ/RPLCMT PG ONLY ISDSS EACH 0680T "$2,325.00 " 960 "$1,627.50 " "$1,162.50 " "$1,860.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349715 PHYSICIAN FEE - SURGERY PF-INSRT/REDO PN/GASTR STIMUL EACH 64590 $793.00 960 $555.10 $396.50 $634.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323157 PHYSICIAN FEE - SURGERY PF-INST PULSE GEN W/DUAL LEADS EACH 33230 "$1,032.00 " 960 $722.40 $516.00 $825.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323165 PHYSICIAN FEE - SURGERY PF-INST PULSE GEN W/MULT LEADS EACH 33231 "$1,100.00 " 960 $770.00 $550.00 $880.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347321 PHYSICIAN FEE - SURGERY PF-INST/REDO NEUROSTIM 1 ARRAY EACH 61885 "$1,544.00 " 960 "$1,080.80 " $772.00 "$1,235.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349053 PHYSICIAN FEE - SURGERY PF-INST/REDO SPINE N GENERATOR EACH 63685 $945.00 960 $661.50 $472.50 $756.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349152 PHYSICIAN FEE - SURGERY PF-INSTALL SPINAL SHUNT EACH 63741 "$2,007.00 " 960 "$1,404.90 " "$1,003.50 " "$1,605.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349145 PHYSICIAN FEE - SURGERY PF-INSTALL SPINAL SHUNT EACH 63740 "$2,945.00 " 960 "$2,061.50 " "$1,472.50 " "$2,356.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359342 PHYSICIAN FEE - SURGERY PF-INTERCALARY ALGRFT COMPL EACH 20934 "$2,079.00 " 960 "$1,455.30 " "$1,039.50 " "$1,663.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305071 PHYSICIAN FEE - SURGERY PF-INTERDENTAL FIXATION EACH 21110 "$1,826.00 " 960 "$1,278.20 " $913.00 "$1,460.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306293 PHYSICIAN FEE - SURGERY PF-INTERDENTAL WIRING EACH 21497 "$1,508.00 " 960 "$1,055.60 " $754.00 "$1,206.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350085 PHYSICIAN FEE - SURGERY PF-INTERNAL NERVE REVISION EACH 64727 $469.00 960 $328.30 $234.50 $375.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334394 PHYSICIAN FEE - SURGERY PF-INTESTINAL STRICTUROPLASTY EACH 44615 "$2,979.00 " 960 "$2,085.30 " "$1,489.50 " "$2,383.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301443 PHYSICIAN FEE - SURGERY PF-INTMD WND REPAIR N-HG/GENIT EACH 12044 $571.00 960 $399.70 $285.50 $456.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301450 PHYSICIAN FEE - SURGERY PF-INTMD WND REPAIR N-HG/GENIT EACH 12045 $740.00 960 $518.00 $370.00 $592.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301468 PHYSICIAN FEE - SURGERY PF-INTMD WND REPAIR N-HG/GENIT EACH 12046 $888.00 960 $621.60 $444.00 $710.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301476 PHYSICIAN FEE - SURGERY PF-INTMD WND REPAIR N-HG/GENIT EACH 12047 $987.00 960 $690.90 $493.50 $789.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301393 PHYSICIAN FEE - SURGERY PF-INTMD WND REPAIR S/TR/EXT EACH 12035 $654.00 960 $457.80 $327.00 $523.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301401 PHYSICIAN FEE - SURGERY PF-INTMD WND REPAIR S/TR/EXT EACH 12036 $776.00 960 $543.20 $388.00 $620.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301419 PHYSICIAN FEE - SURGERY PF-INTMD WND REPAIR S/TR/EXT EACH 12037 $904.00 960 $632.80 $452.00 $723.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346935 PHYSICIAN FEE - SURGERY PF-INTRACRANIAL VESSEL SURGERY EACH 61680 "$6,849.00 " 960 "$4,794.30 " "$3,424.50 " "$5,479.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346943 PHYSICIAN FEE - SURGERY PF-INTRACRANIAL VESSEL SURGERY EACH 61682 "$12,636.00 " 960 "$8,845.20 " "$6,318.00 " "$10,108.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346950 PHYSICIAN FEE - SURGERY PF-INTRACRANIAL VESSEL SURGERY EACH 61684 "$8,586.00 " 960 "$6,010.20 " "$4,293.00 " "$6,868.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346968 PHYSICIAN FEE - SURGERY PF-INTRACRANIAL VESSEL SURGERY EACH 61686 "$13,582.00 " 960 "$9,507.40 " "$6,791.00 " "$10,865.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346976 PHYSICIAN FEE - SURGERY PF-INTRACRANIAL VESSEL SURGERY EACH 61690 "$6,587.00 " 960 "$4,610.90 " "$3,293.50 " "$5,269.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346984 PHYSICIAN FEE - SURGERY PF-INTRACRANIAL VESSEL SURGERY EACH 61692 "$11,034.00 " 960 "$7,723.80 " "$5,517.00 " "$8,827.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320187 PHYSICIAN FEE - SURGERY PF-INTRANASAL RECONSTRUCTION EACH 30620 "$1,776.00 " 960 "$1,243.20 " $888.00 "$1,420.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334493 PHYSICIAN FEE - SURGERY PF-INTRAOP COLON LAVAGE ADD-ON EACH 44701 $482.00 960 $337.40 $241.00 $385.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358880 PHYSICIAN FEE - SURGERY PF-INTRO CATH DIALYSIS CIRCUIT EACH 36901 $448.00 960 $313.60 $224.00 $358.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334345 PHYSICIAN FEE - SURGERY PF-INTRO GASTROINTESTINAL TUBE EACH 44500 $50.00 960 $35.00 $25.00 $40.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321672 PHYSICIAN FEE - SURGERY PF-INTRO WINDPIPE WIRE/TUBE EACH 31730 $412.00 960 $288.40 $206.00 $329.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359730 PHYSICIAN FEE - SURGERY PF-INTRVASC US NONCORONARY 1ST EACH 37252 $244.00 960 $170.80 $122.00 $195.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359748 PHYSICIAN FEE - SURGERY PF-INTRVASC US NONCORONARY ADD EACH 37253 $193.00 960 $135.10 $96.50 $154.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329915 PHYSICIAN FEE - SURGERY PF-IO MAP OF SENT LYMPH NODE EACH 38900 $388.00 960 $271.60 $194.00 $310.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320294 PHYSICIAN FEE - SURGERY PF-IRRIGATION MAXILLARY SINUS EACH 31000 $293.00 960 $205.10 $146.50 $234.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339740 PHYSICIAN FEE - SURGERY PF-IRRIGATION OF BLADDER EACH 51700 $81.00 960 $56.70 $40.50 $64.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320302 PHYSICIAN FEE - SURGERY PF-IRRIGATION SPHENOID SINUS EACH 31002 $493.00 960 $345.10 $246.50 $394.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302334 PHYSICIAN FEE - SURGERY PF-ISLAND PEDICLE FLAP GRAFT EACH 15740 "$2,252.00 " 960 "$1,576.40 " "$1,126.00 " "$1,801.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319080 PHYSICIAN FEE - SURGERY PF-JAW ARTHROSCOPY/SURGERY EACH 29800 "$1,465.00 " 960 "$1,025.50 " $732.50 "$1,172.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319098 PHYSICIAN FEE - SURGERY PF-JAW ARTHROSCOPY/SURGERY EACH 29804 "$1,560.00 " 960 "$1,092.00 " $780.00 "$1,248.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358914 PHYSICIAN FEE - SURGERY PF-KERATOMILEUSIS EACH 65760 $500.00 960 $350.00 $250.00 $400.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351216 PHYSICIAN FEE - SURGERY PF-KERATPLASTY PENETRAT PSEUDO EACH 65755 "$3,209.00 " 960 "$2,246.30 " "$1,604.50 " "$2,567.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338783 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY EACH 50551 $774.00 960 $541.80 $387.00 $619.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338791 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY EACH 50553 $828.00 960 $579.60 $414.00 $662.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338841 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY EACH 50570 "$1,296.00 " 960 $907.20 $648.00 "$1,036.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338858 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY EACH 50572 "$1,398.00 " 960 $978.60 $699.00 "$1,118.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338874 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY EACH 50575 "$1,877.00 " 960 "$1,313.90 " $938.50 "$1,501.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338809 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY & BIOPSY EACH 50555 $898.00 960 $628.60 $449.00 $718.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338866 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY & BIOPSY EACH 50574 "$1,486.00 " 960 "$1,040.20 " $743.00 "$1,188.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338817 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY & TX EACH 50557 $909.00 960 $636.30 $454.50 $727.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338825 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY & TX EACH 50561 "$1,041.00 " 960 $728.70 $520.50 $832.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338882 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY & TX EACH 50576 "$1,481.00 " 960 "$1,036.70 " $740.50 "$1,184.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338890 PHYSICIAN FEE - SURGERY PF-KIDNEY ENDOSCOPY & TX EACH 50580 "$1,598.00 " 960 "$1,118.60 " $799.00 "$1,278.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319478 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY DX EACH 29870 "$1,128.00 " 960 $789.60 $564.00 $902.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319486 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/DRAINAGE EACH 29871 "$1,418.00 " 960 $992.60 $709.00 "$1,134.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319361 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29850 "$1,723.00 " 960 "$1,206.10 " $861.50 "$1,378.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319379 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29851 "$2,562.00 " 960 "$1,793.40 " "$1,281.00 " "$2,049.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319494 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29873 "$1,472.00 " 960 "$1,030.40 " $736.00 "$1,177.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319502 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29874 "$1,483.00 " 960 "$1,038.10 " $741.50 "$1,186.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319510 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29875 "$1,367.00 " 960 $956.90 $683.50 "$1,093.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319528 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29876 "$1,795.00 " 960 "$1,256.50 " $897.50 "$1,436.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319536 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29877 "$1,707.00 " 960 "$1,194.90 " $853.50 "$1,365.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319544 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29879 "$1,821.00 " 960 "$1,274.70 " $910.50 "$1,456.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319551 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29880 "$1,545.00 " 960 "$1,081.50 " $772.50 "$1,236.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319569 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29881 "$1,487.00 " 960 "$1,040.90 " $743.50 "$1,189.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319577 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29882 "$1,890.00 " 960 "$1,323.00 " $945.00 "$1,512.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319585 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29883 "$2,322.00 " 960 "$1,625.40 " "$1,161.00 " "$1,857.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319593 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29884 "$1,704.00 " 960 "$1,192.80 " $852.00 "$1,363.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319601 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29885 "$2,085.00 " 960 "$1,459.50 " "$1,042.50 " "$1,668.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319619 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29886 "$1,756.00 " 960 "$1,229.20 " $878.00 "$1,404.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319627 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29887 "$2,078.00 " 960 "$1,454.60 " "$1,039.00 " "$1,662.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319635 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29888 "$2,671.00 " 960 "$1,869.70 " "$1,335.50 " "$2,136.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319643 PHYSICIAN FEE - SURGERY PF-KNEE ARTHROSCOPY/SURGERY EACH 29889 "$3,373.00 " 960 "$2,361.10 " "$1,686.50 " "$2,698.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307267 PHYSICIAN FEE - SURGERY PF-KYPHECTOMY 1-2 SEGMENTS EACH 22818 "$5,928.00 " 960 "$4,149.60 " "$2,964.00 " "$4,742.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307275 PHYSICIAN FEE - SURGERY PF-KYPHECTOMY 3 OR MORE EACH 22819 "$6,821.00 " 960 "$4,774.70 " "$3,410.50 " "$5,456.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333933 PHYSICIAN FEE - SURGERY PF-L COLECTOMY/COLOPROCTOSTOMY EACH 44207 "$4,986.00 " 960 "$3,490.20 " "$2,493.00 " "$3,988.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333941 PHYSICIAN FEE - SURGERY PF-L COLECTOMY/COLOPROCTOSTOMY EACH 44208 "$5,418.00 " 960 "$3,792.60 " "$2,709.00 " "$4,334.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323108 PHYSICIAN FEE - SURGERY PF-L VENTRC PACING LEAD ADD-ON EACH 33225 "$1,275.00 " 960 $892.50 $637.50 "$1,020.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361017 PHYSICIAN FEE - SURGERY PF-LAM FACTC/FRMT ARTH LUM 1 EACH 63052 $752.00 960 $526.40 $376.00 $601.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361025 PHYSICIAN FEE - SURGERY PF-LAM FACTC/FRMT ARTH LUM ADD EACH 63053 $669.00 960 $468.30 $334.50 $535.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348188 PHYSICIAN FEE - SURGERY PF-LAMINOTOMY ADDL CERVICAL EACH 63043 $881.00 960 $616.70 $440.50 $704.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348196 PHYSICIAN FEE - SURGERY PF-LAMINOTOMY ADDL LUMBAR EACH 63044 $830.00 960 $581.00 $415.00 $664.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348162 PHYSICIAN FEE - SURGERY PF-LAMINOTOMY SINGLE CERVICAL EACH 63040 "$3,973.00 " 960 "$2,781.10 " "$1,986.50 " "$3,178.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348170 PHYSICIAN FEE - SURGERY PF-LAMINOTOMY SINGLE LUMBAR EACH 63042 "$3,725.00 " 960 "$2,607.50 " "$1,862.50 " "$2,980.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333990 PHYSICIAN FEE - SURGERY PF-LAP CLOSE ENTEROSTOMY EACH 44227 "$4,606.00 " 960 "$3,224.20 " "$2,303.00 " "$3,684.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333917 PHYSICIAN FEE - SURGERY PF-LAP COLECTOMY PART W/ILEUM EACH 44205 "$3,690.00 " 960 "$2,583.00 " "$1,845.00 " "$2,952.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333966 PHYSICIAN FEE - SURGERY PF-LAP COLECTOMY W/PROCTECTOMY EACH 44211 "$5,613.00 " 960 "$3,929.10 " "$2,806.50 " "$4,490.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333875 PHYSICIAN FEE - SURGERY PF-LAP COLOSTOMY EACH 44188 "$3,355.00 " 960 "$2,348.50 " "$1,677.50 " "$2,684.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333883 PHYSICIAN FEE - SURGERY PF-LAP ENTERECTOMY EACH 44202 "$3,896.00 " 960 "$2,727.20 " "$1,948.00 " "$3,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333842 PHYSICIAN FEE - SURGERY PF-LAP ENTEROLYSIS EACH 44180 "$2,598.00 " 960 "$1,818.60 " "$1,299.00 " "$2,078.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332513 PHYSICIAN FEE - SURGERY PF-LAP ESOPH LENGTHENING EACH 43283 $448.00 960 $313.60 $224.00 $358.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333073 PHYSICIAN FEE - SURGERY PF-LAP GASTR BYPASS INC SMLL I EACH 43645 "$5,239.00 " 960 "$3,667.30 " "$2,619.50 " "$4,191.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333065 PHYSICIAN FEE - SURGERY PF-LAP GASTRC BYPASS/ROUX-EN-Y EACH 43644 "$4,939.00 " 960 "$3,457.30 " "$2,469.50 " "$3,951.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333867 PHYSICIAN FEE - SURGERY PF-LAP ILEO/JEJUNO-STOMY EACH 44187 "$2,981.00 " 960 "$2,086.70 " "$1,490.50 " "$2,384.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333081 PHYSICIAN FEE - SURGERY PF-LAP IMPL ELECTRODE ANTRUM EACH 43647 "$3,434.00 " 960 "$2,403.80 " "$1,717.00 " "$2,747.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338007 PHYSICIAN FEE - SURGERY PF-LAP ING HERNIA REPAIR INIT EACH 49650 "$1,222.00 " 960 $855.40 $611.00 $977.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338015 PHYSICIAN FEE - SURGERY PF-LAP ING HERNIA REPAIR RECUR EACH 49651 "$1,597.00 " 960 "$1,117.90 " $798.50 "$1,277.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337389 PHYSICIAN FEE - SURGERY PF-LAP INS DEVICE FOR RT EACH 49327 $370.00 960 $259.00 $185.00 $296.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337355 PHYSICIAN FEE - SURGERY PF-LAP INSERT TUNNEL IP CATH EACH 49324 "$1,096.00 " 960 $767.20 $548.00 $876.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333859 PHYSICIAN FEE - SURGERY PF-LAP JEJUNOSTOMY EACH 44186 "$1,842.00 " 960 "$1,289.40 " $921.00 "$1,473.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333982 PHYSICIAN FEE - SURGERY PF-LAP MOBIL SPLENIC FL ADD-ON EACH 44213 $515.00 960 $360.50 $257.50 $412.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332471 PHYSICIAN FEE - SURGERY PF-LAP MYOTOMY HELLER EACH 43279 "$3,634.00 " 960 "$2,543.80 " "$1,817.00 " "$2,907.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332497 PHYSICIAN FEE - SURGERY PF-LAP PARAESOPHAG HERN REPAIR EACH 43281 "$4,360.00 " 960 "$3,052.00 " "$2,180.00 " "$3,488.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332505 PHYSICIAN FEE - SURGERY PF-LAP PARAESPH HER RPR W/MESH EACH 43282 "$4,915.00 " 960 "$3,440.50 " "$2,457.50 " "$3,932.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333925 PHYSICIAN FEE - SURGERY PF-LAP PART COLECTOMY W/STOMA EACH 44206 "$4,840.00 " 960 "$3,388.00 " "$2,420.00 " "$3,872.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333214 PHYSICIAN FEE - SURGERY PF-LAP PLACE GASTR ADJ DEVICE EACH 43770 "$3,190.00 " 960 "$2,233.00 " "$1,595.00 " "$2,552.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335193 PHYSICIAN FEE - SURGERY PF-LAP PROCTOPEXY W/SIG RESECT EACH 45402 "$4,148.00 " 960 "$2,903.60 " "$2,074.00 " "$3,318.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344286 PHYSICIAN FEE - SURGERY PF-LAP RADICAL HYST EACH 58548 "$5,146.00 " 960 "$3,602.20 " "$2,573.00 " "$4,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335169 PHYSICIAN FEE - SURGERY PF-LAP REMOVAL OF RECTUM EACH 45395 "$5,317.00 " 960 "$3,721.90 " "$2,658.50 " "$4,253.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335177 PHYSICIAN FEE - SURGERY PF-LAP REMOVE RECTUM W/POUCH EACH 45397 "$5,717.00 " 960 "$4,001.90 " "$2,858.50 " "$4,573.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333248 PHYSICIAN FEE - SURGERY PF-LAP REPL GASTR ADJ DEVICE EACH 43773 "$3,626.00 " 960 "$2,538.20 " "$1,813.00 " "$2,900.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333891 PHYSICIAN FEE - SURGERY PF-LAP RESECT S/INTESTINE ADDL EACH 44203 $676.00 960 $473.20 $338.00 $540.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333222 PHYSICIAN FEE - SURGERY PF-LAP REVISE GASTR ADJ DEVICE EACH 43771 "$3,626.00 " 960 "$2,538.20 " "$1,813.00 " "$2,900.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333099 PHYSICIAN FEE - SURGERY PF-LAP REVISE/REM ELTRD ANTRUM EACH 43648 "$3,949.00 " 960 "$2,764.30 " "$1,974.50 " "$3,159.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337363 PHYSICIAN FEE - SURGERY PF-LAP REVISION PERM IP CATH EACH 49325 "$1,170.00 " 960 $819.00 $585.00 $936.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333255 PHYSICIAN FEE - SURGERY PF-LAP RMV GASTR ADJ ALL PARTS EACH 43774 "$2,727.00 " 960 "$1,908.90 " "$1,363.50 " "$2,181.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333230 PHYSICIAN FEE - SURGERY PF-LAP RMVL GASTR ADJ DEVICE EACH 43772 "$2,699.00 " 960 "$1,889.30 " "$1,349.50 " "$2,159.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333263 PHYSICIAN FEE - SURGERY PF-LAP SLEEVE GASTRECTOMY EACH 43775 "$3,163.00 " 960 "$2,214.10 " "$1,581.50 " "$2,530.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337371 PHYSICIAN FEE - SURGERY PF-LAP W/OMENTOPEXY ADD-ON EACH 49326 $537.00 960 $375.90 $268.50 $429.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342413 PHYSICIAN FEE - SURGERY PF-LAPAR LIGATE SPERMATIC VEIN EACH 55550 "$1,146.00 " 960 $802.20 $573.00 $916.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336340 PHYSICIAN FEE - SURGERY PF-LAPARO ABLATE LIVER CRYOSUR EACH 47371 "$3,577.00 " 960 "$2,503.90 " "$1,788.50 " "$2,861.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336332 PHYSICIAN FEE - SURGERY PF-LAPARO ABLATE LIVER TUM RF EACH 47370 "$3,553.00 " 960 "$2,487.10 " "$1,776.50 " "$2,842.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338700 PHYSICIAN FEE - SURGERY PF-LAPARO ABLATE RENAL CYST EACH 50541 "$2,436.00 " 960 "$1,705.20 " "$1,218.00 " "$1,948.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336605 PHYSICIAN FEE - SURGERY PF-LAPARO CHOLECYSTECTMY/EXPLR EACH 47564 "$3,166.00 " 960 "$2,216.20 " "$1,583.00 " "$2,532.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336597 PHYSICIAN FEE - SURGERY PF-LAPARO CHOLECYSTECTOMY/GRPH EACH 47563 "$2,034.00 " 960 "$1,423.80 " "$1,017.00 " "$1,627.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336613 PHYSICIAN FEE - SURGERY PF-LAPARO CHOLECYSTOENTEROSTMY EACH 47570 "$2,204.00 " 960 "$1,542.80 " "$1,102.00 " "$1,763.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337348 PHYSICIAN FEE - SURGERY PF-LAPARO DRAIN LYMPHOCELE EACH 49323 "$1,788.00 " 960 "$1,251.60 " $894.00 "$1,430.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339328 PHYSICIAN FEE - SURGERY PF-LAPARO NEW URETER/BLADDER EACH 50947 "$3,669.00 " 960 "$2,568.30 " "$1,834.50 " "$2,935.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339336 PHYSICIAN FEE - SURGERY PF-LAPARO NEW URETER/BLADDER EACH 50948 "$3,361.00 " 960 "$2,352.70 " "$1,680.50 " "$2,688.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359185 PHYSICIAN FEE - SURGERY PF-LAPARO OVIDUCT-OVARY NOS EACH 58679 $432.00 960 $302.40 $216.00 $345.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333909 PHYSICIAN FEE - SURGERY PF-LAPARO PARTIAL COLECTOMY EACH 44204 "$4,268.00 " 960 "$2,987.60 " "$2,134.00 " "$3,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338726 PHYSICIAN FEE - SURGERY PF-LAPARO PARTIAL NEPHRECTOMY EACH 50543 "$3,947.00 " 960 "$2,762.90 " "$1,973.50 " "$3,157.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358658 PHYSICIAN FEE - SURGERY PF-LAPARO PROC HERNIA REPAIR EACH 34715 $843.00 960 $590.10 $421.50 $674.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338742 PHYSICIAN FEE - SURGERY PF-LAPARO RADICAL NEPHRECTOMY EACH 50545 "$3,538.00 " 960 "$2,476.60 " "$1,769.00 " "$2,830.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342637 PHYSICIAN FEE - SURGERY PF-LAPARO RADICAL PROSTATECTMY EACH 55866 "$3,170.00 " 960 "$2,219.00 " "$1,585.00 " "$2,536.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338767 PHYSICIAN FEE - SURGERY PF-LAPARO REMOVAL DONOR KIDNEY EACH 50547 "$4,540.00 " 960 "$3,178.00 " "$2,270.00 " "$3,632.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338775 PHYSICIAN FEE - SURGERY PF-LAPARO REMOVE W/URETER EACH 50548 "$3,559.00 " 960 "$2,491.30 " "$1,779.50 " "$2,847.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340094 PHYSICIAN FEE - SURGERY PF-LAPARO SLING OPERATION EACH 51992 "$2,270.00 " 960 "$1,589.00 " "$1,135.00 " "$1,816.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333958 PHYSICIAN FEE - SURGERY PF-LAPARO TOTAL PROCTOCOLECTMY EACH 44210 "$4,820.00 " 960 "$3,374.00 " "$2,410.00 " "$3,856.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333974 PHYSICIAN FEE - SURGERY PF-LAPARO TOTAL PROCTOCOLECTMY EACH 44212 "$5,467.00 " 960 "$3,826.90 " "$2,733.50 " "$4,373.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340086 PHYSICIAN FEE - SURGERY PF-LAPARO URETHRAL SUSPENSION EACH 51990 "$1,981.00 " 960 "$1,386.70 " $990.50 "$1,584.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357767 PHYSICIAN FEE - SURGERY PF-LAPARO/ABDM/PER/OMENT NOS EACH 49329 $383.00 960 $268.10 $191.50 $306.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344278 PHYSICIAN FEE - SURGERY PF-LAPARO-MYOMECTOMY COMPLEX EACH 58546 "$3,055.00 " 960 "$2,138.50 " "$1,527.50 " "$2,444.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357189 PHYSICIAN FEE - SURGERY PF-LAPAROSC ISLET CELL TRANS EACH G0342 "$2,134.00 " 960 "$1,493.80 " "$1,067.00 " "$1,707.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360464 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPE PROC BILIAR NOS EACH 47579 "$1,811.00 " 960 "$1,267.70 " $905.50 "$1,448.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360456 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPE PROC LIVER NOS EACH 47379 "$1,811.00 " 960 "$1,267.70 " $905.50 "$1,448.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358674 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPE PROC LIVER NOS EACH 36465 $327.00 960 $228.90 $163.50 $261.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358518 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPE PROC URETER NOS EACH 34701 "$3,459.00 " 960 "$2,421.30 " "$1,729.50 " "$2,767.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336589 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPIC CHOLECYSTECTMY EACH 47562 "$1,870.00 " 960 "$1,309.00 " $935.00 "$1,496.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344260 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPIC MYOMECTOMY EACH 58545 "$2,477.00 " 960 "$1,733.90 " "$1,238.50 " "$1,981.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338759 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPIC NEPHRECTOMY EACH 50546 "$3,208.00 " 960 "$2,245.60 " "$1,604.00 " "$2,566.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335185 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPIC PROC EACH 45400 "$3,070.00 " 960 "$2,149.00 " "$1,535.00 " "$2,456.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345739 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY ADRENALECTOMY EACH 60650 "$3,325.00 " 960 "$2,327.50 " "$1,662.50 " "$2,660.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334592 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY APPENDECTOMY EACH 44970 "$1,701.00 " 960 "$1,190.70 " $850.50 "$1,360.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337330 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY ASPIRATION EACH 49322 "$1,052.00 " 960 $736.40 $526.00 $841.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337322 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY BIOPSY EACH 49321 $963.00 960 $674.10 $481.50 $770.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344518 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY EXCISE LESIONS EACH 58662 "$1,956.00 " 960 "$1,369.20 " $978.00 "$1,564.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344542 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY FIMBRIOPLASTY EACH 58672 "$2,004.00 " 960 "$1,402.80 " "$1,002.00 " "$1,603.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332489 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY FUNDOPLASTY EACH 43280 "$3,054.00 " 960 "$2,137.80 " "$1,527.00 " "$2,443.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333123 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY GASTROSTOMY EACH 43653 "$1,628.00 " 960 "$1,139.60 " $814.00 "$1,302.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329741 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY LYMPH NODE BIOP EACH 38570 "$1,411.00 " 960 $987.70 $705.50 "$1,128.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329758 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY LYMPHADENECTOMY EACH 38571 "$1,767.00 " 960 "$1,236.90 " $883.50 "$1,413.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329766 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY LYMPHADENECTOMY EACH 38572 "$2,435.00 " 960 "$1,704.50 " "$1,217.50 " "$1,948.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344492 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY LYSIS EACH 58660 "$1,898.00 " 960 "$1,328.60 " $949.00 "$1,518.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342108 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY ORCHIECTOMY EACH 54690 "$1,743.00 " 960 "$1,220.10 " $871.50 "$1,394.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342116 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY ORCHIOPEXY EACH 54692 "$2,006.00 " 960 "$1,404.20 " "$1,003.00 " "$1,604.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358534 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY PROC NOS RECTUM EACH 34703 "$3,848.00 " 960 "$2,693.60 " "$1,924.00 " "$3,078.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357874 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY PROC UTERUS NOS EACH 58578 "$2,723.00 " 960 "$1,906.10 " "$1,361.50 " "$2,178.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338734 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY PYELOPLASTY EACH 50544 "$3,285.00 " 960 "$2,299.50 " "$1,642.50 " "$2,628.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344500 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY REMOVE ADNEXA EACH 58661 "$1,788.00 " 960 "$1,251.60 " $894.00 "$1,430.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344559 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY SALPINGOSTOMY EACH 58673 "$2,174.00 " 960 "$1,521.80 " "$1,087.00 " "$1,739.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329451 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY SPLENECTOMY EACH 38120 "$2,994.00 " 960 "$2,095.80 " "$1,497.00 " "$2,395.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343569 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY SURG COLPOPEXY EACH 57425 "$2,646.00 " 960 "$1,852.20 " "$1,323.00 " "$2,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344534 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY TUBAL BLOCK EACH 58671 "$1,017.00 " 960 $711.90 $508.50 $813.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344526 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY TUBAL CAUTERY EACH 58670 "$1,017.00 " 960 $711.90 $508.50 $813.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339310 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY URETEROLITHOTMY EACH 50945 "$2,571.00 " 960 "$1,799.70 " "$1,285.50 " "$2,056.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333107 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY VAGUS NERVE EACH 43651 "$1,863.00 " 960 "$1,304.10 " $931.50 "$1,490.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333115 PHYSICIAN FEE - SURGERY PF-LAPAROSCOPY VAGUS NERVE EACH 43652 "$2,175.00 " 960 "$1,522.50 " "$1,087.50 " "$1,740.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357197 PHYSICIAN FEE - SURGERY PF-LAPAROTOMY ISLET CELL TRANS EACH G0343 "$3,497.00 " 960 "$2,447.90 " "$1,748.50 " "$2,797.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344310 PHYSICIAN FEE - SURGERY PF-LAPARO-VAG HYST COMPLEX EACH 58553 "$3,072.00 " 960 "$2,150.40 " "$1,536.00 " "$2,457.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344302 PHYSICIAN FEE - SURGERY PF-LAPARO-VAG HYST INCL T/O EACH 58552 "$2,683.00 " 960 "$1,878.10 " "$1,341.50 " "$2,146.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344328 PHYSICIAN FEE - SURGERY PF-LAPARO-VAG HYST W/T/O COMPL EACH 58554 "$3,575.00 " 960 "$2,502.50 " "$1,787.50 " "$2,860.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357932 PHYSICIAN FEE - SURGERY PF-LAPARSCPY PROC STOMACH NOS EACH 43659 "$1,663.00 " 960 "$1,164.10 " $831.50 "$1,330.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357890 PHYSICIAN FEE - SURGERY PF-LAPRSCPY PROC INTESTINE NOS EACH 44238 $719.00 960 $503.30 $359.50 $575.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360225 PHYSICIAN FEE - SURGERY PF-LAPS ABLTJ UTERINE FIBROIDS EACH 58674 "$2,226.00 " 960 "$1,558.20 " "$1,113.00 " "$1,780.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359763 PHYSICIAN FEE - SURGERY PF-LAPS ESOPHGL SPHNCTR AGMNTJ EACH 43284 "$1,848.00 " 960 "$1,293.60 " $924.00 "$1,478.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502314 PHYSICIAN FEE - SURGERY PF-LAPS INSJ N/RPCMT ISDSS 1LD EACH 0675T "$1,550.00 " 960 "$1,085.00 " $775.00 "$1,240.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502306 PHYSICIAN FEE - SURGERY PF-LAPS INSJ N/RPCMT PRM ISDSS EACH 0674T "$1,550.00 " 960 "$1,085.00 " $775.00 "$1,240.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502322 PHYSICIAN FEE - SURGERY PF-LAPS INSJ NW/RPCMT ISDSS EA EACH 0676T "$1,451.00 " 960 "$1,015.70 " $725.50 "$1,160.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502330 PHYSICIAN FEE - SURGERY PF-LAPS REP LEAD ISDSS 1ST LD EACH 0677T "$1,550.00 " 960 "$1,085.00 " $775.00 "$1,240.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502355 PHYSICIAN FEE - SURGERY PF-LAPS REP LEAD ISDSS EA ADD EACH 0678T "$2,943.00 " 960 "$2,060.10 " "$1,471.50 " "$2,354.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502363 PHYSICIAN FEE - SURGERY PF-LAPS RMVL LEAD ISDSS EACH 0679T $370.00 960 $259.00 $185.00 $296.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361488 PHYSICIAN FEE - SURGERY PF-LAPS SURG PRST8ECT SMPL STO EACH 55867 "$2,782.00 " 960 "$1,947.40 " "$1,391.00 " "$2,225.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359177 PHYSICIAN FEE - SURGERY PF-LARGSC W/LASER DSTR LES UNI EACH 31572 $483.00 960 $338.10 $241.50 $386.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359482 PHYSICIAN FEE - SURGERY PF-LARGSC W/NJX AUGMENTATION EACH 31574 $401.00 960 $280.70 $200.50 $320.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359474 PHYSICIAN FEE - SURGERY PF-LARGSC W/THER INJECTION EACH 31573 $398.00 960 $278.60 $199.00 $318.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359433 PHYSICIAN FEE - SURGERY PF-LARYNGOPLASTY LARYNG STEN EACH 31551 "$4,115.00 " 960 "$2,880.50 " "$2,057.50 " "$3,292.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359458 PHYSICIAN FEE - SURGERY PF-LARYNGOPLASTY LARYNG STEN EACH 31553 "$4,466.00 " 960 "$3,126.20 " "$2,233.00 " "$3,572.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359466 PHYSICIAN FEE - SURGERY PF-LARYNGOPLASTY LARYNG STEN EACH 31554 "$4,468.00 " 960 "$3,127.60 " "$2,234.00 " "$3,574.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358864 PHYSICIAN FEE - SURGERY PF-LARYNGOPLASTY MEDIALIZATION EACH 31591 "$2,598.00 " 960 "$1,818.60 " "$1,299.00 " "$2,078.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358732 PHYSICIAN FEE - SURGERY PF-LARYNGOPLSTY LARYNGEAL STEN EACH 43286 "$8,925.00 " 960 "$6,247.50 " "$4,462.50 " "$7,140.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321094 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOP W/ARYTENOIDECT EACH 31560 $835.00 960 $584.50 $417.50 $668.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321128 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOP W/VC INJ+SCOPE EACH 31571 $666.00 960 $466.20 $333.00 $532.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321110 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPE W/VC INJ EACH 31570 $617.00 960 $431.90 $308.50 $493.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320997 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY AND DILATION EACH 31528 $387.00 960 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321003 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY AND DILATION EACH 31529 $432.00 960 $302.40 $216.00 $345.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320948 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY FOR ASPIRATION EACH 31515 $296.00 960 $207.20 $148.00 $236.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320989 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY FOR TREATMENT EACH 31527 $521.00 960 $364.70 $260.50 $416.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321037 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY W/BIOPSY EACH 31535 $506.00 960 $354.20 $253.00 $404.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321045 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY W/BX&OP SCOPE EACH 31536 $562.00 960 $393.40 $281.00 $449.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321052 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY W/EXC OF TUMOR EACH 31540 $645.00 960 $451.50 $322.50 $516.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321011 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY W/FB REMOVAL EACH 31530 $534.00 960 $373.80 $267.00 $427.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321029 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY W/FB&OP SCOPE EACH 31531 $564.00 960 $394.80 $282.00 $451.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320906 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY WITH BIOPSY EACH 31510 $324.00 960 $226.80 $162.00 $259.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321144 PHYSICIAN FEE - SURGERY PF-LARYNGOSCOPY WITH BIOPSY EACH 31576 $320.00 960 $224.00 $160.00 $256.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321102 PHYSICIAN FEE - SURGERY PF-LARYNSCOP REMVE CART + SCOP EACH 31561 $913.00 960 $639.10 $456.50 $730.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321060 PHYSICIAN FEE - SURGERY PF-LARYNSCOP W/TUMR EXC+SCOPE EACH 31541 $704.00 960 $492.80 $352.00 $563.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341324 PHYSICIAN FEE - SURGERY PF-LASER SURG PENIS LESION(S) EACH 54057 $260.00 960 $182.00 $130.00 $208.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336001 PHYSICIAN FEE - SURGERY PF-LASER SURGERY ANAL LESIONS EACH 46917 $349.00 960 $244.30 $174.50 $279.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352024 PHYSICIAN FEE - SURGERY PF-LASER SURGERY EYE STRANDS EACH 67031 $902.00 960 $631.40 $451.00 $721.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343684 PHYSICIAN FEE - SURGERY PF-LASER SURGERY OF CERVIX EACH 57513 $397.00 960 $277.90 $198.50 $317.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340664 PHYSICIAN FEE - SURGERY PF-LASER SURGERY OF PROSTATE EACH 52647 "$1,727.00 " 960 "$1,208.90 " $863.50 "$1,381.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340672 PHYSICIAN FEE - SURGERY PF-LASER SURGERY OF PROSTATE EACH 52648 "$1,841.00 " 960 "$1,288.70 " $920.50 "$1,472.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352040 PHYSICIAN FEE - SURGERY PF-LASER TREATMENT OF RETINA EACH 67039 "$2,450.00 " 960 "$1,715.00 " "$1,225.00 " "$1,960.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357676 PHYSICIAN FEE - SURGERY PF-LASER TX SKIN >500 SQ CM EACH 96922 $292.00 960 $204.40 $146.00 $233.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307002 PHYSICIAN FEE - SURGERY PF-LAT LUMBAR SPINE FUSION EACH 22533 "$4,699.00 " 960 "$3,289.30 " "$2,349.50 " "$3,759.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314818 PHYSICIAN FEE - SURGERY PF-LAT RETINACULR RELEASE OPEN EACH 27425 "$1,253.00 " 960 $877.10 $626.50 "$1,002.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307010 PHYSICIAN FEE - SURGERY PF-LAT THOR/LUMB ADDL SEG EACH 22534 "$1,041.00 " 960 $728.70 $520.50 $832.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306996 PHYSICIAN FEE - SURGERY PF-LAT THORAX SPINE FUSION EACH 22532 "$5,208.00 " 960 "$3,645.60 " "$2,604.00 " "$4,166.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301674 PHYSICIAN FEE - SURGERY PF-LATE CLOSURE OF WOUND EACH 13160 "$2,154.00 " 960 "$1,507.80 " "$1,077.00 " "$1,723.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305717 PHYSICIAN FEE - SURGERY PF-LATERAL CANTHOPEXY EACH 21282 "$1,048.00 " 960 $733.60 $524.00 $838.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325582 PHYSICIAN FEE - SURGERY PF-LEG VEIN FUSION EACH 34530 "$2,656.00 " 960 "$1,859.20 " "$1,328.00 " "$2,124.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312507 PHYSICIAN FEE - SURGERY PF-LENGTHEN METACARPAL/FINGER EACH 26568 "$2,506.00 " 960 "$1,754.20 " "$1,253.00 " "$2,004.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310485 PHYSICIAN FEE - SURGERY PF-LENGTHEN RADIUS & ULNA EACH 25393 "$3,114.00 " 960 "$2,179.80 " "$1,557.00 " "$2,491.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310469 PHYSICIAN FEE - SURGERY PF-LENGTHEN RADIUS OR ULNA EACH 25391 "$2,744.00 " 960 "$1,920.80 " "$1,372.00 " "$2,195.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312077 PHYSICIAN FEE - SURGERY PF-LENGTHENING OF HAND TENDON EACH 26478 "$1,762.00 " 960 "$1,233.40 " $881.00 "$1,409.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331051 PHYSICIAN FEE - SURGERY PF-LENGTHENING OF PALATE EACH 42226 "$2,394.00 " 960 "$1,675.80 " "$1,197.00 " "$1,915.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331069 PHYSICIAN FEE - SURGERY PF-LENGTHENING OF PALATE EACH 42227 "$2,234.00 " 960 "$1,563.80 " "$1,117.00 " "$1,787.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315021 PHYSICIAN FEE - SURGERY PF-LENGTHENING OF THIGH BONE EACH 27466 "$3,263.00 " 960 "$2,284.10 " "$1,631.50 " "$2,610.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314644 PHYSICIAN FEE - SURGERY PF-LENGTHENING OF THIGH TENDON EACH 27393 "$1,380.00 " 960 $966.00 $690.00 "$1,104.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314651 PHYSICIAN FEE - SURGERY PF-LENGTHENING THIGH TENDONS EACH 27394 "$1,809.00 " 960 "$1,266.30 " $904.50 "$1,447.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314669 PHYSICIAN FEE - SURGERY PF-LENGTHENING THIGH TENDONS EACH 27395 "$2,433.00 " 960 "$1,703.10 " "$1,216.50 " "$1,946.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335128 PHYSICIAN FEE - SURGERY PF-LESION REMOVAL COLONOSCOPY EACH 45385 $667.00 960 $466.90 $333.50 $533.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335110 PHYSICIAN FEE - SURGERY PF-LESION REMOVE COLONOSCOPY EACH 45384 $610.00 960 $427.00 $305.00 $488.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332778 PHYSICIAN FEE - SURGERY PF-LIGATE ESOPHAGUS VEINS EACH 43400 "$4,328.00 " 960 "$3,029.60 " "$2,164.00 " "$3,462.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329345 PHYSICIAN FEE - SURGERY PF-LIGATE LEG VEINS OPEN EACH 37761 "$1,501.00 " 960 "$1,050.70 " $750.50 "$1,200.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329337 PHYSICIAN FEE - SURGERY PF-LIGATE LEG VEINS RADICAL EACH 37760 "$1,628.00 " 960 "$1,139.60 " $814.00 "$1,302.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344476 PHYSICIAN FEE - SURGERY PF-LIGATE OVIDUCT(S) ADD-ON EACH 58611 $207.00 960 $144.90 $103.50 $165.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329386 PHYSICIAN FEE - SURGERY PF-LIGATE/DIVIDE/EXCISE VEIN EACH 37785 $709.00 960 $496.30 $354.50 $567.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332794 PHYSICIAN FEE - SURGERY PF-LIGATE/STAPLE ESOPHAGUS EACH 43405 "$4,096.00 " 960 "$2,867.20 " "$2,048.00 " "$3,276.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329311 PHYSICIAN FEE - SURGERY PF-LIGATE/STRIP LONG LEG VEIN EACH 37722 "$1,297.00 " 960 $907.90 $648.50 "$1,037.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329303 PHYSICIAN FEE - SURGERY PF-LIGATE/STRIP SHORT LEG VEIN EACH 37718 "$1,107.00 " 960 $774.90 $553.50 $885.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329253 PHYSICIAN FEE - SURGERY PF-LIGATION EXTREMITY ARTERY EACH 37618 "$1,092.00 " 960 $764.40 $546.00 $873.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320260 PHYSICIAN FEE - SURGERY PF-LIGATION NASAL SINUS ARTERY EACH 30915 "$1,609.00 " 960 "$1,126.30 " $804.50 "$1,287.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329246 PHYSICIAN FEE - SURGERY PF-LIGATION OF ABDOMEN ARTERY EACH 37617 "$3,707.00 " 960 "$2,594.90 " "$1,853.50 " "$2,965.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329204 PHYSICIAN FEE - SURGERY PF-LIGATION OF A-V FISTULA EACH 37607 "$1,042.00 " 960 $729.40 $521.00 $833.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329238 PHYSICIAN FEE - SURGERY PF-LIGATION OF CHEST ARTERY EACH 37616 "$3,158.00 " 960 "$2,210.60 " "$1,579.00 " "$2,526.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329261 PHYSICIAN FEE - SURGERY PF-LIGATION OF INF VENA CAVA EACH 37619 "$4,904.00 " 960 "$3,432.80 " "$2,452.00 " "$3,923.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329170 PHYSICIAN FEE - SURGERY PF-LIGATION OF NECK ARTERY EACH 37600 "$2,029.00 " 960 "$1,420.30 " "$1,014.50 " "$1,623.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329188 PHYSICIAN FEE - SURGERY PF-LIGATION OF NECK ARTERY EACH 37605 "$2,090.00 " 960 "$1,463.00 " "$1,045.00 " "$1,672.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329196 PHYSICIAN FEE - SURGERY PF-LIGATION OF NECK ARTERY EACH 37606 "$2,162.00 " 960 "$1,513.40 " "$1,081.00 " "$1,729.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329220 PHYSICIAN FEE - SURGERY PF-LIGATION OF NECK ARTERY EACH 37615 "$1,410.00 " 960 $987.00 $705.00 "$1,128.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329162 PHYSICIAN FEE - SURGERY PF-LIGATION OF NECK VEIN EACH 37565 "$2,003.00 " 960 "$1,402.10 " "$1,001.50 " "$1,602.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331382 PHYSICIAN FEE - SURGERY PF-LIGATION OF SALIVARY DUCT EACH 42665 $583.00 960 $408.10 $291.50 $466.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337546 PHYSICIAN FEE - SURGERY PF-LIGATION OF SHUNT EACH 49428 "$1,221.00 " 960 $854.70 $610.50 $976.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320278 PHYSICIAN FEE - SURGERY PF-LIGATION UPPER JAW ARTERY EACH 30920 "$2,324.00 " 960 "$1,626.80 " "$1,162.00 " "$1,859.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350275 PHYSICIAN FEE - SURGERY PF-LIMB NERVE SURGERY ADD-ON EACH 64783 $592.00 960 $414.40 $296.00 $473.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360993 PHYSICIAN FEE - SURGERY PF-LITT ICR 1 TRAJ 1 SMPL LES EACH 61736 "$3,632.00 " 960 "$2,542.40 " "$1,816.00 " "$2,905.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361009 PHYSICIAN FEE - SURGERY PF-LITT ICR MLT TRJ MLT/CPL LS EACH 61737 "$4,420.00 " 960 "$3,094.00 " "$2,210.00 " "$3,536.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348147 PHYSICIAN FEE - SURGERY PF-LOW BACK DISK SURGERY EACH 63030 "$2,635.00 " 960 "$1,844.50 " "$1,317.50 " "$2,108.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305493 PHYSICIAN FEE - SURGERY PF-LOWER JAW BONE GRAFT EACH 21215 "$2,062.00 " 960 "$1,443.40 " "$1,031.00 " "$1,649.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344229 PHYSICIAN FEE - SURGERY PF-LSH UTERUS 250 G OR LESS EACH 58541 "$1,991.00 " 960 "$1,393.70 " $995.50 "$1,592.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344245 PHYSICIAN FEE - SURGERY PF-LSH UTERUS ABOVE 250 G EACH 58543 "$2,307.00 " 960 "$1,614.90 " "$1,153.50 " "$1,845.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344237 PHYSICIAN FEE - SURGERY PF-LSH W/T/O UT 250 G OR LESS EACH 58542 "$2,265.00 " 960 "$1,585.50 " "$1,132.50 " "$1,812.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344252 PHYSICIAN FEE - SURGERY PF-LSH W/T/O UTERUS ABOVE 250G EACH 58544 "$2,481.00 " 960 "$1,736.70 " "$1,240.50 " "$1,984.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307432 PHYSICIAN FEE - SURGERY PF-LUMBAR ARTIF DISKECTOMY EACH 22857 "$4,812.00 " 960 "$3,368.40 " "$2,406.00 " "$3,849.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307077 PHYSICIAN FEE - SURGERY PF-LUMBAR SPINE FUSION EACH 22558 "$4,357.00 " 960 "$3,049.90 " "$2,178.50 " "$3,485.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307143 PHYSICIAN FEE - SURGERY PF-LUMBAR SPINE FUSION EACH 22612 "$4,521.00 " 960 "$3,164.70 " "$2,260.50 " "$3,616.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307168 PHYSICIAN FEE - SURGERY PF-LUMBAR SPINE FUSION EACH 22630 "$4,584.00 " 960 "$3,208.80 " "$2,292.00 " "$3,667.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307184 PHYSICIAN FEE - SURGERY PF-LUMBAR SPINE FUSION COMB EACH 22633 "$5,234.00 " 960 "$3,663.80 " "$2,617.00 " "$4,187.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322688 PHYSICIAN FEE - SURGERY PF-LUNG TRANSPLANT DOUBLE EACH 32853 "$12,855.00 " 960 "$8,998.50 " "$6,427.50 " "$10,284.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322662 PHYSICIAN FEE - SURGERY PF-LUNG TRANSPLANT SINGLE EACH 32851 "$9,188.00 " 960 "$6,431.60 " "$4,594.00 " "$7,350.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322670 PHYSICIAN FEE - SURGERY PF-LUNG TRANSPLANT WITH BYPASS EACH 32852 "$9,838.00 " 960 "$6,886.60 " "$4,919.00 " "$7,870.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322696 PHYSICIAN FEE - SURGERY PF-LUNG TRANSPLANT WITH BYPASS EACH 32854 "$13,612.00 " 960 "$9,528.40 " "$6,806.00 " "$10,889.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322134 PHYSICIAN FEE - SURGERY PF-LUNG VOLUME REDUCTION EACH 32491 "$4,129.00 " 960 "$2,890.30 " "$2,064.50 " "$3,303.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329550 PHYSICIAN FEE - SURGERY PF-LYMPHOCYTE INFUSE TRANSPLNT EACH 38242 $322.00 960 $225.40 $161.00 $257.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322308 PHYSICIAN FEE - SURGERY PF-LYSE CHEST FIBRIN INIT DAY EACH 32561 $178.00 960 $124.60 $89.00 $142.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322316 PHYSICIAN FEE - SURGERY PF-LYSE CHEST FIBRIN SUBQ DAY EACH 32562 $158.00 960 $110.60 $79.00 $126.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342728 PHYSICIAN FEE - SURGERY PF-LYSIS OF LABIAL LESION(S) EACH 56441 $418.00 960 $292.60 $209.00 $334.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341480 PHYSICIAN FEE - SURGERY PF-LYSIS PENIL CIRCUMIC LESION EACH 54162 $533.00 960 $373.10 $266.50 $426.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324635 PHYSICIAN FEE - SURGERY PF-MAJOR VESSEL SHUNT EACH 33750 "$3,542.00 " 960 "$2,479.40 " "$1,771.00 " "$2,833.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324643 PHYSICIAN FEE - SURGERY PF-MAJOR VESSEL SHUNT EACH 33755 "$3,698.00 " 960 "$2,588.60 " "$1,849.00 " "$2,958.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324650 PHYSICIAN FEE - SURGERY PF-MAJOR VESSEL SHUNT EACH 33762 "$3,599.00 " 960 "$2,519.30 " "$1,799.50 " "$2,879.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324676 PHYSICIAN FEE - SURGERY PF-MAJOR VESSEL SHUNT EACH 33766 "$3,739.00 " 960 "$2,617.30 " "$1,869.50 " "$2,991.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324684 PHYSICIAN FEE - SURGERY PF-MAJOR VESSEL SHUNT EACH 33767 "$3,993.00 " 960 "$2,795.10 " "$1,996.50 " "$3,194.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324668 PHYSICIAN FEE - SURGERY PF-MAJOR VESSEL SHUNT & GRAFT EACH 33764 "$3,698.00 " 960 "$2,588.60 " "$1,849.00 " "$2,958.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340987 PHYSICIAN FEE - SURGERY PF-MALE SLING PROCEDURE EACH 53440 "$2,000.00 " 960 "$1,400.00 " "$1,000.00 " "$1,600.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311731 PHYSICIAN FEE - SURGERY PF-MANIPULAT PALM CORD PST INJ EACH 26341 $212.00 960 $148.40 $106.00 $169.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308943 PHYSICIAN FEE - SURGERY PF-MANIPULATE ELBOW W/ANESTH EACH 24300 "$1,194.00 " 960 $835.80 $597.00 $955.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311723 PHYSICIAN FEE - SURGERY PF-MANIPULATE FINGER W/ANESTH EACH 26340 $965.00 960 $675.50 $482.50 $772.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310188 PHYSICIAN FEE - SURGERY PF-MANIPULATE WRIST W/ANESTHES EACH 25259 "$1,174.00 " 960 $821.80 $587.00 $939.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314164 PHYSICIAN FEE - SURGERY PF-MANIPULATION OF HIP JOINT EACH 27275 $503.00 960 $352.10 $251.50 $402.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306970 PHYSICIAN FEE - SURGERY PF-MANIPULATION OF SPINE EACH 22505 $363.00 960 $254.10 $181.50 $290.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303688 PHYSICIAN FEE - SURGERY PF-MAST MOD RAD EACH 19307 "$3,325.00 " 960 "$2,327.50 " "$1,662.50 " "$2,660.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303670 PHYSICIAN FEE - SURGERY PF-MAST RAD URBAN TYPE EACH 19306 "$3,438.00 " 960 "$2,406.60 " "$1,719.00 " "$2,750.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303662 PHYSICIAN FEE - SURGERY PF-MAST RADICAL EACH 19305 "$3,236.00 " 960 "$2,265.20 " "$1,618.00 " "$2,588.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303647 PHYSICIAN FEE - SURGERY PF-MAST SIMPLE COMPLETE EACH 19303 "$2,706.00 " 960 "$1,894.20 " "$1,353.00 " "$2,164.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353881 PHYSICIAN FEE - SURGERY PF-MASTOID SURGERY REVISION EACH 69601 "$2,713.00 " 960 "$1,899.10 " "$1,356.50 " "$2,170.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353899 PHYSICIAN FEE - SURGERY PF-MASTOID SURGERY REVISION EACH 69602 "$2,897.00 " 960 "$2,027.90 " "$1,448.50 " "$2,317.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353907 PHYSICIAN FEE - SURGERY PF-MASTOID SURGERY REVISION EACH 69603 "$3,388.00 " 960 "$2,371.60 " "$1,694.00 " "$2,710.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353915 PHYSICIAN FEE - SURGERY PF-MASTOID SURGERY REVISION EACH 69604 "$2,960.00 " 960 "$2,072.00 " "$1,480.00 " "$2,368.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353782 PHYSICIAN FEE - SURGERY PF-MASTOIDECTOMY EACH 69501 "$1,895.00 " 960 "$1,326.50 " $947.50 "$1,516.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353790 PHYSICIAN FEE - SURGERY PF-MASTOIDECTOMY EACH 69502 "$2,519.00 " 960 "$1,763.30 " "$1,259.50 " "$2,015.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305063 PHYSICIAN FEE - SURGERY PF-MAXILLOFACIAL FIXATION EACH 21100 $929.00 960 $650.30 $464.50 $743.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319734 PHYSICIAN FEE - SURGERY PF-MCP JOINT ARTHROSCOPY DX EACH 29900 "$1,388.00 " 960 $971.60 $694.00 "$1,110.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319742 PHYSICIAN FEE - SURGERY PF-MCP JOINT ARTHROSCOPY SURG EACH 29901 "$1,489.00 " 960 "$1,042.30 " $744.50 "$1,191.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319759 PHYSICIAN FEE - SURGERY PF-MCP JOINT ARTHROSCOPY SURG EACH 29902 "$1,582.00 " 960 "$1,107.40 " $791.00 "$1,265.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358401 PHYSICIAN FEE - SURGERY PF-MDFC FLAP W/PRSRV VASC PEDC EACH 15730 "$2,404.00 " 960 "$1,682.80 " "$1,202.00 " "$1,923.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338619 PHYSICIAN FEE - SURGERY PF-MEASURE KIDNEY PRESSURE EACH 50396 $299.00 960 $209.30 $149.50 $239.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339013 PHYSICIAN FEE - SURGERY PF-MEASURE URETER PRESSURE EACH 50686 $235.00 960 $164.50 $117.50 $188.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305709 PHYSICIAN FEE - SURGERY PF-MEDIAL CANTHOPEXY EACH 21280 "$1,534.00 " 960 "$1,073.80 " $767.00 "$1,227.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357825 PHYSICIAN FEE - SURGERY PF-MEDIASTINOSCPY W/MEDSTNL BX EACH 39401 $861.00 960 $602.70 $430.50 $688.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357833 PHYSICIAN FEE - SURGERY PF-MEDIASTINSCPY W/LMPH NOD BX EACH 39402 "$1,130.00 " 960 $791.00 $565.00 $904.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319460 PHYSICIAN FEE - SURGERY PF-MENISCAL TRNSPL KNEE W/SCPE EACH 29868 "$4,594.00 " 960 "$3,215.80 " "$2,297.00 " "$3,675.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354384 PHYSICIAN FEE - SURGERY PF-MICROSURGERY ADD-ON EACH 69990 $656.00 960 $459.20 $328.00 $524.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361173 PHYSICIAN FEE - SURGERY PF-MNL PREP&INS IMED RX DEV EACH 20702 $392.00 960 $274.40 $196.00 $313.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304942 PHYSICIAN FEE - SURGERY PF-MNPJ OF TMJ W/ANESTH EACH 21073 $632.00 960 $442.40 $316.00 $505.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333693 PHYSICIAN FEE - SURGERY PF-MOBILIZATION OF COLON EACH 44139 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303274 PHYSICIAN FEE - SURGERY PF-MOHS 1 STAGE H/N/HF/G EACH 17311 $925.00 960 $647.50 $462.50 $740.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303290 PHYSICIAN FEE - SURGERY PF-MOHS 1 STAGE T/A/L EACH 17313 $831.00 960 $581.70 $415.50 $664.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303308 PHYSICIAN FEE - SURGERY PF-MOHS ADDL STAGE T/A/L EACH 17314 $457.00 960 $319.90 $228.50 $365.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303316 PHYSICIAN FEE - SURGERY PF-MOHS SURG ADDL BLOCK EACH 17315 $131.00 960 $91.70 $65.50 $104.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358559 PHYSICIAN FEE - SURGERY PF-MOUTH SURGERY PROC NOS EACH 34705 "$4,281.00 " 960 "$2,996.70 " "$2,140.50 " "$3,424.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304595 PHYSICIAN FEE - SURGERY PF-MT BONE GRAFT MICROVASC EACH 20957 "$7,559.00 " 960 "$5,291.30 " "$3,779.50 " "$6,047.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358419 PHYSICIAN FEE - SURGERY PF-MUSC MYOQ/FSCQ FLP H&N PEDC EACH 15733 "$2,772.00 " 960 "$1,940.40 " "$1,386.00 " "$2,217.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307978 PHYSICIAN FEE - SURGERY PF-MUSCLE TRANSFERS EACH 23397 "$3,146.00 " 960 "$2,202.20 " "$1,573.00 " "$2,516.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307960 PHYSICIAN FEE - SURGERY PF-MUSCLE XFER SHOULDER/ARM EACH 23395 "$3,525.00 " 960 "$2,467.50 " "$1,762.50 " "$2,820.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308950 PHYSICIAN FEE - SURGERY PF-MUSCLE/TENDON TRANSFER EACH 24301 "$2,069.00 " 960 "$1,448.30 " "$1,034.50 " "$1,655.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302318 PHYSICIAN FEE - SURGERY PF-MUSCLE-SKIN GRAFT ARM EACH 15736 "$3,313.00 " 960 "$2,319.10 " "$1,656.50 " "$2,650.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302326 PHYSICIAN FEE - SURGERY PF-MUSCLE-SKIN GRAFT LEG EACH 15738 "$3,457.00 " 960 "$2,419.90 " "$1,728.50 " "$2,765.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302300 PHYSICIAN FEE - SURGERY PF-MUSCLE-SKIN GRAFT TRUNK EACH 15734 "$4,145.00 " 960 "$2,901.50 " "$2,072.50 " "$3,316.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358500 PHYSICIAN FEE - SURGERY PF-MUSCULOSKELETAL SURG NOS EACH 33927 "$7,172.00 " 960 "$5,020.40 " "$3,586.00 " "$5,737.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360423 PHYSICIAN FEE - SURGERY PF-MUSCULOSKELETAL SURGERY NOS EACH 20999 "$1,078.00 " 960 $754.60 $539.00 $862.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357072 PHYSICIAN FEE - SURGERY PF-MYELOGRAPHY LUMBAR INJ EACH 62303 $309.00 960 $216.30 $154.50 $247.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343874 PHYSICIAN FEE - SURGERY PF-MYOMECTOMY ABDOM COMPLEX EACH 58146 "$3,165.00 " 960 "$2,215.50 " "$1,582.50 " "$2,532.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343858 PHYSICIAN FEE - SURGERY PF-MYOMECTOMY ABDOM METHOD EACH 58140 "$2,524.00 " 960 "$1,766.80 " "$1,262.00 " "$2,019.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343866 PHYSICIAN FEE - SURGERY PF-MYOMECTOMY VAG METHOD EACH 58145 "$1,555.00 " 960 "$1,088.50 " $777.50 "$1,244.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356462 PHYSICIAN FEE - SURGERY PF-N BLK SCIATIC CONT INF BI EACH 64446 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356454 PHYSICIAN FEE - SURGERY PF-N BLK SCIATIC CONT INF LT EACH 64446 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356447 PHYSICIAN FEE - SURGERY PF-N BLK SCIATIC CONT INF RT EACH 64446 $197.00 960 $137.90 $98.50 $157.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355951 PHYSICIAN FEE - SURGERY PF-N BLOCK CONT INF B PLEX BI EACH 64416 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355944 PHYSICIAN FEE - SURGERY PF-N BLOCK CONT INF B PLEX LT EACH 64416 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355936 PHYSICIAN FEE - SURGERY PF-N BLOCK CONT INF B PLEX RT EACH 64416 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355894 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ AXILLARY BI EACH 64417 $168.00 960 $117.60 $84.00 $134.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355886 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ AXILLARY LT EACH 64417 $168.00 960 $117.60 $84.00 $134.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355878 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ AXILLARY RT EACH 64417 $168.00 960 $117.60 $84.00 $134.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355928 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ BRACH PLEXUS BI EACH 64415 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356017 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ CERV PLEXUS BI EACH 64413 $355.00 960 $248.50 $177.50 $284.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356009 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ CERV PLEXUS LT EACH 64413 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355993 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ CERV PLEXUS RT EACH 64413 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349822 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ COMMON DIGIT EACH 64632 $175.00 960 $122.50 $87.50 $140.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356041 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ FACIAL BI EACH 64402 $230.00 960 $161.00 $115.00 $184.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356033 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ FACIAL LT EACH 64402 $230.00 960 $161.00 $115.00 $184.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356025 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ FACIAL RT EACH 64402 $230.00 960 $161.00 $115.00 $184.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356074 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ FEM CONT INF BI EACH 64448 $188.00 960 $131.60 $94.00 $150.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356066 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ FEM CONT INF LT EACH 64448 $188.00 960 $131.60 $94.00 $150.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356058 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ FEM CONT INF RT EACH 64448 $188.00 960 $131.60 $94.00 $150.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356108 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ FEM SINGLE BI EACH 64447 $164.00 960 $114.80 $82.00 $131.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356090 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ FEM SINGLE LT EACH 64447 $164.00 960 $114.80 $82.00 $131.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356082 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ FEM SINGLE RT EACH 64447 $164.00 960 $114.80 $82.00 $131.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349558 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ HYPOGAS PLXS EACH 64517 $328.00 960 $229.60 $164.00 $262.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356132 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ ILIO-ING/HYP BI EACH 64425 $143.00 960 $100.10 $71.50 $114.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356165 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ INTERCST MLT BI EACH 64421 $66.00 960 $46.20 $33.00 $52.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356199 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ LUMB PLEXUS BI EACH 64449 $169.00 960 $118.30 $84.50 $135.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356181 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ LUMB PLEXUS LT EACH 64449 $169.00 960 $118.30 $84.50 $135.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356173 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ LUMB PLEXUS RT EACH 64449 $169.00 960 $118.30 $84.50 $135.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356280 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ OCCIPITAL BI EACH 64405 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356314 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PARACERVICAL BI EACH 64435 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356306 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PARACERVICAL LT EACH 64435 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356298 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PARACERVICAL RT EACH 64435 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356348 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PHRENIC BI EACH 64410 $285.00 960 $199.50 $142.50 $228.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356330 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PHRENIC LT EACH 64410 $190.00 960 $133.00 $95.00 $152.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356322 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PHRENIC RT EACH 64410 $190.00 960 $133.00 $95.00 $152.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356371 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PLANTAR DIG BI EACH 64455 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356363 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PLANTAR DIG LT EACH 64455 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356355 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PLANTAR DIG RT EACH 64455 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356405 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ PUDENDAL BI EACH 64430 $145.00 960 $101.50 $72.50 $116.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356439 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ SCIATIC SNG BI EACH 64445 $189.00 960 $132.30 $94.50 $151.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356645 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ VAGUS BI EACH 64408 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356637 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ VAGUS LT EACH 64408 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356629 PHYSICIAN FEE - SURGERY PF-N BLOCK INJ VAGUS RT EACH 64408 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355860 PHYSICIAN FEE - SURGERY PF-N BLOCK OTHER PERIPHERAL BI EACH 64450 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355852 PHYSICIAN FEE - SURGERY PF-N BLOCK OTHER PERIPHERAL LT EACH 64450 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356611 PHYSICIAN FEE - SURGERY PF-N BLOCK SUPRASCAPULAR BI EACH 64418 $147.00 960 $102.90 $73.50 $117.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356603 PHYSICIAN FEE - SURGERY PF-N BLOCK SUPRASCAPULAR LT EACH 64418 $147.00 960 $102.90 $73.50 $117.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356595 PHYSICIAN FEE - SURGERY PF-N BLOCK SUPRASCAPULAR RT EACH 64418 $147.00 960 $102.90 $73.50 $117.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319981 PHYSICIAN FEE - SURGERY PF-NASAL SINUS THERAPY EACH 30210 $273.00 960 $191.10 $136.50 $218.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358526 PHYSICIAN FEE - SURGERY PF-NASAL SURGERY PROCEDURE NOS EACH 34702 "$5,190.00 " 960 "$3,633.00 " "$2,595.00 " "$4,152.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333131 PHYSICIAN FEE - SURGERY PF-NASAL/OROGASTRIC W/STENT EACH 43752 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320534 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY DX EACH 31235 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320575 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31240 $427.00 960 $298.90 $213.50 $341.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320542 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31237 $429.00 960 $300.30 $214.50 $343.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320559 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31238 $449.00 960 $314.30 $224.50 $359.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320567 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31239 "$1,593.00 " 960 "$1,115.10 " $796.50 "$1,274.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320633 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31287 $539.00 960 $377.30 $269.50 $431.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320641 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31288 $629.00 960 $440.30 $314.50 $503.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320658 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31290 "$3,076.00 " 960 "$2,153.20 " "$1,538.00 " "$2,460.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320666 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31291 "$3,349.00 " 960 "$2,344.30 " "$1,674.50 " "$2,679.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320674 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31292 "$2,651.00 " 960 "$1,855.70 " "$1,325.50 " "$2,120.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320682 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31293 "$2,884.00 " 960 "$2,018.80 " "$1,442.00 " "$2,307.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320690 PHYSICIAN FEE - SURGERY PF-NASAL/SINUS ENDOSCOPY SURG EACH 31294 "$3,294.00 " 960 "$2,305.80 " "$1,647.00 " "$2,635.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353469 PHYSICIAN FEE - SURGERY PF-NASOLACRIMAL DUCT PROBING EACH 68810 $327.00 960 $228.90 $163.50 $261.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321417 PHYSICIAN FEE - SURGERY PF-NAVIGATIONAL BRONCHOSCOPY EACH 31627 $251.00 960 $175.70 $125.50 $200.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360910 PHYSICIAN FEE - SURGERY PF-NDOVAG CRYG RF REMDL TISS EACH 0672T "$1,550.00 " 960 "$1,085.00 " $775.00 "$1,240.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502454 PHYSICIAN FEE - SURGERY PF-NDSC HRV UXTR ART 1 SGM CAB EACH 33509 $483.00 960 $338.10 $241.50 $386.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307119 PHYSICIAN FEE - SURGERY PF-NECK SPINAL FUSION EACH 22595 "$4,477.00 " 960 "$3,133.90 " "$2,238.50 " "$3,581.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348139 PHYSICIAN FEE - SURGERY PF-NECK SPINE DISK SURGERY EACH 63020 "$3,176.00 " 960 "$2,223.20 " "$1,588.00 " "$2,540.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348311 PHYSICIAN FEE - SURGERY PF-NECK SPINE DISK SURGERY EACH 63075 "$3,929.00 " 960 "$2,750.30 " "$1,964.50 " "$3,143.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348329 PHYSICIAN FEE - SURGERY PF-NECK SPINE DISK SURGERY EACH 63076 $696.00 960 $487.20 $348.00 $556.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307036 PHYSICIAN FEE - SURGERY PF-NECK SPINE FUSE&REMOVE ADDL EACH 22551 "$4,959.00 " 960 "$3,471.30 " "$2,479.50 " "$3,967.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307028 PHYSICIAN FEE - SURGERY PF-NECK SPINE FUSION EACH 22548 "$5,903.00 " 960 "$4,132.10 " "$2,951.50 " "$4,722.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307051 PHYSICIAN FEE - SURGERY PF-NECK SPINE FUSION EACH 22554 "$3,667.00 " 960 "$2,566.90 " "$1,833.50 " "$2,933.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307127 PHYSICIAN FEE - SURGERY PF-NECK SPINE FUSION EACH 22600 "$3,801.00 " 960 "$2,660.70 " "$1,900.50 " "$3,040.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322035 PHYSICIAN FEE - SURGERY PF-NEEDLE BIOPSY CHEST LINING EACH 32400 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336100 PHYSICIAN FEE - SURGERY PF-NEEDLE BIOPSY LIVER ADD-ON EACH 47001 $293.00 960 $205.10 $146.50 $234.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303985 PHYSICIAN FEE - SURGERY PF-NEEDLE BIOPSY MUSCLE EACH 20206 $149.00 960 $104.30 $74.50 $119.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347743 PHYSICIAN FEE - SURGERY PF-NEEDLE BIOPSY SPINAL CORD EACH 62269 $670.00 960 $469.00 $335.00 $536.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359276 PHYSICIAN FEE - SURGERY PF-NEG PRESS WOUND TX <50 CM EACH 97607 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359268 PHYSICIAN FEE - SURGERY PF-NEG PRESS WOUND TX >50 CM EACH 97606 $67.00 960 $46.90 $33.50 $53.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350739 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT ADD-ON EACH 64901 "$1,631.00 " 960 "$1,141.70 " $815.50 "$1,304.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350747 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT ADD-ON EACH 64902 "$1,886.00 " 960 "$1,320.20 " $943.00 "$1,508.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350671 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT ARM OR LEG EACH 64892 "$2,893.00 " 960 "$2,025.10 " "$1,446.50 " "$2,314.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350689 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT ARM OR LEG EACH 64893 "$3,084.00 " 960 "$2,158.80 " "$1,542.00 " "$2,467.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350713 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT ARM OR LEG EACH 64897 "$2,831.00 " 960 "$1,981.70 " "$1,415.50 " "$2,264.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350721 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT ARM OR LEG EACH 64898 "$3,773.00 " 960 "$2,641.10 " "$1,886.50 " "$3,018.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350655 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT HAND OR FOOT EACH 64890 "$2,972.00 " 960 "$2,080.40 " "$1,486.00 " "$2,377.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350663 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT HAND OR FOOT EACH 64891 "$3,161.00 " 960 "$2,212.70 " "$1,580.50 " "$2,528.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350697 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT HAND OR FOOT EACH 64895 "$3,644.00 " 960 "$2,550.80 " "$1,822.00 " "$2,915.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350705 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT HAND OR FOOT EACH 64896 "$3,932.00 " 960 "$2,752.40 " "$1,966.00 " "$3,145.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350630 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT HEAD OR NECK EACH 64885 "$2,887.00 " 960 "$2,020.90 " "$1,443.50 " "$2,309.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350648 PHYSICIAN FEE - SURGERY PF-NERVE GRAFT HEAD OR NECK EACH 64886 "$3,467.00 " 960 "$2,426.90 " "$1,733.50 " "$2,773.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350754 PHYSICIAN FEE - SURGERY PF-NERVE PEDICLE TRANSFER EACH 64905 "$2,743.00 " 960 "$1,920.10 " "$1,371.50 " "$2,194.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350770 PHYSICIAN FEE - SURGERY PF-NERVE REPAIR W/ALLOGRAFT EACH 64910 "$2,059.00 " 960 "$1,441.30 " "$1,029.50 " "$1,647.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350531 PHYSICIAN FEE - SURGERY PF-NERVE SURGERY EACH 64859 $680.00 960 $476.00 $340.00 $544.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317001 PHYSICIAN FEE - SURGERY PF-NEURECTOMY FOOT EACH 28055 "$1,032.00 " 960 $722.40 $516.00 $825.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314313 PHYSICIAN FEE - SURGERY PF-NEURECTOMY HAMSTRING EACH 27325 "$1,559.00 " 960 "$1,091.30 " $779.50 "$1,247.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314321 PHYSICIAN FEE - SURGERY PF-NEURECTOMY POPLITEAL EACH 27326 "$1,441.00 " 960 "$1,008.70 " $720.50 "$1,152.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349632 PHYSICIAN FEE - SURGERY PF-NEUROELTRD STIM POST TIBIAL EACH 64566 $82.00 960 $57.40 $41.00 $65.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347511 PHYSICIAN FEE - SURGERY PF-NEUROENDOSCOPY ADD-ON EACH 62160 $570.00 960 $399.00 $285.00 $456.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356785 PHYSICIAN FEE - SURGERY PF-NEUROLYTC OTHER PERIPH N BI EACH 64640 $313.00 960 $219.10 $156.50 $250.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356777 PHYSICIAN FEE - SURGERY PF-NEUROLYTC OTHER PERIPH N LT EACH 64640 $313.00 960 $219.10 $156.50 $250.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356769 PHYSICIAN FEE - SURGERY PF-NEUROLYTC OTHER PERIPH N RT EACH 64640 $313.00 960 $219.10 $156.50 $250.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349731 PHYSICIAN FEE - SURGERY PF-NEUROLYTIC TRIGEMINAL NERVE EACH 64600 $661.00 960 $462.70 $330.50 $528.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350788 PHYSICIAN FEE - SURGERY PF-NEURORRAPHY W/VEIN AUTOGRFT EACH 64911 "$2,798.00 " 960 "$1,958.60 " "$1,399.00 " "$2,238.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302342 PHYSICIAN FEE - SURGERY PF-NEUROVASCULAR PEDICLE GRAFT EACH 15750 "$2,546.00 " 960 "$1,782.20 " "$1,273.00 " "$2,036.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324809 PHYSICIAN FEE - SURGERY PF-NIKAIDOH PROC EACH 33782 "$9,063.00 " 960 "$6,344.10 " "$4,531.50 " "$7,250.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324817 PHYSICIAN FEE - SURGERY PF-NIKAIDOH PROC W/OSTIA IMPLT EACH 33783 "$9,799.00 " 960 "$6,859.30 " "$4,899.50 " "$7,839.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303464 PHYSICIAN FEE - SURGERY PF-NIPPLE EXPLORATION EACH 19110 $984.00 960 $688.80 $492.00 $787.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359417 PHYSICIAN FEE - SURGERY PF-NJX CNTRST KNE ARTHG/CT/MRI EACH 27369 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360266 PHYSICIAN FEE - SURGERY PF-NJX INTERLAMINAR CRV/THRC EACH 62320 $268.00 960 $187.60 $134.00 $214.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360282 PHYSICIAN FEE - SURGERY PF-NJX INTERLAMINAR CRV/THRC EACH 62324 $232.00 960 $162.40 $116.00 $185.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360274 PHYSICIAN FEE - SURGERY PF-NJX INTERLAMINAR LMBR/SAC EACH 62322 $210.00 960 $147.00 $105.00 $168.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360290 PHYSICIAN FEE - SURGERY PF-NJX INTERLAMINAR LMBR/SAC EACH 62326 $223.00 960 $156.10 $111.50 $178.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327869 PHYSICIAN FEE - SURGERY PF-NON-ROUTINE BL DRAW > 3 YRS EACH 36410 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358476 PHYSICIAN FEE - SURGERY PF-NSL/SINS NDSC SPHN TISS RMV EACH 31259 "$1,264.00 " 960 $884.80 $632.00 "$1,011.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358468 PHYSICIAN FEE - SURGERY PF-NSL/SINS NDSC TOT W/SPHENDT EACH 31257 "$1,198.00 " 960 $838.60 $599.00 $958.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358450 PHYSICIAN FEE - SURGERY PF-NSL/SINS NDSC TOTAL EACH 31253 "$1,342.00 " 960 $939.40 $671.00 "$1,073.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358443 PHYSICIAN FEE - SURGERY PF-NSL/SINS NDSC W/ARTERY LIG EACH 31241 "$1,199.00 " 960 $839.30 $599.50 $959.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358484 PHYSICIAN FEE - SURGERY PF-NSL/SINS NDSC W/SINS DILAT EACH 31298 $687.00 960 $480.90 $343.50 $549.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345135 PHYSICIAN FEE - SURGERY PF-OBSTETRICAL CARE EACH 59400 "$6,896.00 " 960 "$4,827.20 " "$3,448.00 " "$5,516.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345150 PHYSICIAN FEE - SURGERY PF-OBSTETRICAL CARE EACH 59410 "$3,118.00 " 960 "$2,182.60 " "$1,559.00 " "$2,494.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344484 PHYSICIAN FEE - SURGERY PF-OCCLUDE FALLOPIAN TUBE(S) EACH 58615 $692.00 960 $484.40 $346.00 $553.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352255 PHYSICIAN FEE - SURGERY PF-OCULAR PHOTODYNAMIC THER EACH 67221 $531.00 960 $371.70 $265.50 $424.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351299 PHYSICIAN FEE - SURGERY PF-OCULAR RECONST TRANSPLANT EACH 65780 "$1,510.00 " 960 "$1,057.00 " $755.00 "$1,208.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351307 PHYSICIAN FEE - SURGERY PF-OCULAR RECONST TRANSPLANT EACH 65781 "$3,387.00 " 960 "$2,370.90 " "$1,693.50 " "$2,709.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351315 PHYSICIAN FEE - SURGERY PF-OCULAR RECONST TRANSPLANT EACH 65782 "$2,925.00 " 960 "$2,047.50 " "$1,462.50 " "$2,340.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338098 PHYSICIAN FEE - SURGERY PF-OMENTAL FLAP EXTRA-ABDOM EACH 49904 "$3,868.00 " 960 "$2,707.60 " "$1,934.00 " "$3,094.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338106 PHYSICIAN FEE - SURGERY PF-OMENTAL FLAP INTRA-ABDOM EACH 49905 $992.00 960 $694.40 $496.00 $793.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336365 PHYSICIAN FEE - SURGERY PF-OPEN ABLATE LIVER TUM CRYO EACH 47381 "$4,210.00 " 960 "$2,947.00 " "$2,105.00 " "$3,368.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336357 PHYSICIAN FEE - SURGERY PF-OPEN ABLATE LIVER TUMOR RF EACH 47380 "$4,085.00 " 960 "$2,859.50 " "$2,042.50 " "$3,268.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325715 PHYSICIAN FEE - SURGERY PF-OPEN AORTIC TUBE PROSTH REP EACH 34830 "$4,991.00 " 960 "$3,493.70 " "$2,495.50 " "$3,992.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325731 PHYSICIAN FEE - SURGERY PF-OPEN AORTOFEMOR PROSTH REPR EACH 34832 "$5,368.00 " 960 "$3,757.60 " "$2,684.00 " "$4,294.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325723 PHYSICIAN FEE - SURGERY PF-OPEN AORTOILIAC PROSTH REPR EACH 34831 "$5,449.00 " 960 "$3,814.30 " "$2,724.50 " "$4,359.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321870 PHYSICIAN FEE - SURGERY PF-OPEN BIOPSY OF LUNG PLEURA EACH 32098 "$2,117.00 " 960 "$1,481.90 " "$1,058.50 " "$1,693.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304033 PHYSICIAN FEE - SURGERY PF-OPEN BONE BIOPSY EACH 20250 "$1,105.00 " 960 $773.50 $552.50 $884.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304041 PHYSICIAN FEE - SURGERY PF-OPEN BONE BIOPSY EACH 20251 "$1,177.00 " 960 $823.90 $588.50 $941.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334006 PHYSICIAN FEE - SURGERY PF-OPEN BOWEL TO SKIN EACH 44300 "$2,378.00 " 960 "$1,664.60 " "$1,189.00 " "$1,902.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358997 PHYSICIAN FEE - SURGERY PF-OPEN BX/EXC INGUINOFM NODES EACH 38531 "$1,256.00 " 960 $879.20 $628.00 "$1,004.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321961 PHYSICIAN FEE - SURGERY PF-OPEN CHEST HEART MASSAGE EACH 32160 "$2,218.00 " 960 "$1,552.60 " "$1,109.00 " "$1,774.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324221 PHYSICIAN FEE - SURGERY PF-OPEN CORONARY ENDARTERECTMY EACH 33572 $648.00 960 $453.60 $324.00 $518.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336118 PHYSICIAN FEE - SURGERY PF-OPEN DRAINAGE LIVER LESION EACH 47010 "$3,420.00 " 960 "$2,394.00 " "$1,710.00 " "$2,736.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345960 PHYSICIAN FEE - SURGERY PF-OPEN SKULL FOR DRAINAGE EACH 61312 "$6,253.00 " 960 "$4,377.10 " "$3,126.50 " "$5,002.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345978 PHYSICIAN FEE - SURGERY PF-OPEN SKULL FOR DRAINAGE EACH 61313 "$5,982.00 " 960 "$4,187.40 " "$2,991.00 " "$4,785.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345986 PHYSICIAN FEE - SURGERY PF-OPEN SKULL FOR DRAINAGE EACH 61314 "$5,493.00 " 960 "$3,845.10 " "$2,746.50 " "$4,394.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345994 PHYSICIAN FEE - SURGERY PF-OPEN SKULL FOR DRAINAGE EACH 61315 "$6,248.00 " 960 "$4,373.60 " "$3,124.00 " "$4,998.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346018 PHYSICIAN FEE - SURGERY PF-OPEN SKULL FOR DRAINAGE EACH 61320 "$5,711.00 " 960 "$3,997.70 " "$2,855.50 " "$4,568.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346026 PHYSICIAN FEE - SURGERY PF-OPEN SKULL FOR DRAINAGE EACH 61321 "$6,413.00 " 960 "$4,489.10 " "$3,206.50 " "$5,130.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345945 PHYSICIAN FEE - SURGERY PF-OPEN SKULL FOR EXPLORATION EACH 61304 "$4,933.00 " 960 "$3,453.10 " "$2,466.50 " "$3,946.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345952 PHYSICIAN FEE - SURGERY PF-OPEN SKULL FOR EXPLORATION EACH 61305 "$6,051.00 " 960 "$4,235.70 " "$3,025.50 " "$4,840.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328586 PHYSICIAN FEE - SURGERY PF-OPEN THROMBECT AV FISTULA EACH 36831 "$1,728.00 " 960 "$1,209.60 " $864.00 "$1,382.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357213 PHYSICIAN FEE - SURGERY PF-OPEN TX ILIAC SPINE UNI/BIL EACH G0412 "$1,999.00 " 960 "$1,399.30 " $999.50 "$1,599.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357247 PHYSICIAN FEE - SURGERY PF-OPEN TX POST PELVIC FXCTURE EACH G0415 "$3,782.00 " 960 "$2,647.40 " "$1,891.00 " "$3,025.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321854 PHYSICIAN FEE - SURGERY PF-OPEN WEDGE/BX LUNG INFILTR EACH 32096 "$2,240.00 " 960 "$1,568.00 " "$1,120.00 " "$1,792.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321862 PHYSICIAN FEE - SURGERY PF-OPEN WEDGE/BX LUNG NODULE EACH 32097 "$2,243.00 " 960 "$1,570.10 " "$1,121.50 " "$1,794.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332240 PHYSICIAN FEE - SURGERY PF-OPERATIVE UPPER GI ENDOSCPY EACH 43247 $466.00 960 $326.20 $233.00 $372.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332281 PHYSICIAN FEE - SURGERY PF-OPERATIVE UPPER GI ENDOSCPY EACH 43251 $514.00 960 $359.80 $257.00 $411.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332307 PHYSICIAN FEE - SURGERY PF-OPERATIVE UPPER GI ENDOSCPY EACH 43255 $523.00 960 $366.10 $261.50 $418.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351943 PHYSICIAN FEE - SURGERY PF-OPHTHALMIC ENDOSCOPE ADD-ON EACH 66990 $226.00 960 $158.20 $113.00 $180.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361033 PHYSICIAN FEE - SURGERY PF-OPN MPLTJ HPGLSL NST ARY PG EACH 64582 "$2,253.00 " 960 "$1,577.10 " "$1,126.50 " "$1,802.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316375 PHYSICIAN FEE - SURGERY PF-OPTX MEDIAL ANKLE FX EACH 27766 "$1,654.00 " 960 "$1,157.80 " $827.00 "$1,323.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354483 PHYSICIAN FEE - SURGERY PF-OPTX OF RIB FX W/FIXJ SCOPE EACH 21811 "$1,675.00 " 960 "$1,172.50 " $837.50 "$1,340.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316409 PHYSICIAN FEE - SURGERY PF-OPTX POST ANKLE FX EACH 27769 "$1,995.00 " 960 "$1,396.50 " $997.50 "$1,596.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314156 PHYSICIAN FEE - SURGERY PF-OPTX THIGH FX EACH 27269 "$3,416.00 " 960 "$2,391.20 " "$1,708.00 " "$2,732.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357437 PHYSICIAN FEE - SURGERY PF-ORBIT UNLISTED PROCEDURE EACH 67599 "$2,217.00 " 960 "$1,551.90 " "$1,108.50 " "$1,773.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346638 PHYSICIAN FEE - SURGERY PF-ORBITOCRAN APPROACH/SKULL EACH 61584 "$8,448.00 " 960 "$5,913.60 " "$4,224.00 " "$6,758.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346646 PHYSICIAN FEE - SURGERY PF-ORBITOCRAN APPROACH/SKULL EACH 61585 "$9,715.00 " 960 "$6,800.50 " "$4,857.50 " "$7,772.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346687 PHYSICIAN FEE - SURGERY PF-ORBITOCRAN APPROACH/SKULL EACH 61592 "$9,351.00 " 960 "$6,545.70 " "$4,675.50 " "$7,480.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341985 PHYSICIAN FEE - SURGERY PF-ORCHIECTOMY PARTIAL EACH 54522 "$1,563.00 " 960 "$1,094.10 " $781.50 "$1,250.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342066 PHYSICIAN FEE - SURGERY PF-ORCHIOPXY (FOWLER-STEPHENS) EACH 54650 "$1,895.00 " 960 "$1,326.50 " $947.50 "$1,516.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359326 PHYSICIAN FEE - SURGERY PF-OSTEOART ALGRFT W/SURF & B1 EACH 20932 "$2,081.00 " 960 "$1,456.70 " "$1,040.50 " "$1,664.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314750 PHYSICIAN FEE - SURGERY PF-OSTEOCHONDRAL KNEE ALLOGRFT EACH 27415 "$3,778.00 " 960 "$2,644.60 " "$1,889.00 " "$3,022.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314768 PHYSICIAN FEE - SURGERY PF-OSTEOCHONDRL KNEE AUTOGRFT EACH 27416 "$2,702.00 " 960 "$1,891.40 " "$1,351.00 " "$2,161.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318017 PHYSICIAN FEE - SURGERY PF-OSTEOCHONDRL TALUS AUTOGRFT EACH 28446 "$3,372.00 " 960 "$2,360.40 " "$1,686.00 " "$2,697.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304603 PHYSICIAN FEE - SURGERY PF-OT/PTHER BONE GRAFT MICROVASC EACH 20962 "$7,319.00 " 960 "$5,123.30 " "$3,659.50 " "$5,855.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357528 PHYSICIAN FEE - SURGERY PF-OUTER EAR SURGERY PROC NOS EACH 69399 "$1,348.00 " 960 $943.60 $674.00 "$1,078.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301351 PHYSICIAN FEE - SURGERY PF-PACK WOUND DEHISCENCE SUPER EACH 12021 $379.00 960 $265.30 $189.50 $303.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357734 PHYSICIAN FEE - SURGERY "PF-PALATE, UVULA UNLISTED PROC" EACH 42299 $431.00 960 $301.70 $215.50 $344.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336944 PHYSICIAN FEE - SURGERY PF-PANCREATECTOMY EACH 48146 "$5,331.00 " 960 "$3,731.70 " "$2,665.50 " "$4,264.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336977 PHYSICIAN FEE - SURGERY PF-PANCREATECTOMY EACH 48152 "$8,184.00 " 960 "$5,728.80 " "$4,092.00 " "$6,547.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336985 PHYSICIAN FEE - SURGERY PF-PANCREATECTOMY EACH 48153 "$8,797.00 " 960 "$6,157.90 " "$4,398.50 " "$7,037.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336993 PHYSICIAN FEE - SURGERY PF-PANCREATECTOMY EACH 48154 "$8,221.00 " 960 "$5,754.70 " "$4,110.50 " "$6,576.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337066 PHYSICIAN FEE - SURGERY PF-PANCREATORRHAPHY EACH 48545 "$3,823.00 " 960 "$2,676.10 " "$1,911.50 " "$3,058.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331317 PHYSICIAN FEE - SURGERY PF-PAROTID DUCT DIVERSION EACH 42507 "$1,322.00 " 960 $925.40 $661.00 "$1,057.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331325 PHYSICIAN FEE - SURGERY PF-PAROTID DUCT DIVERSION EACH 42509 "$2,189.00 " 960 "$1,532.30 " "$1,094.50 " "$1,751.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331333 PHYSICIAN FEE - SURGERY PF-PAROTID DUCT DIVERSION EACH 42510 "$1,627.00 " 960 "$1,138.90 " $813.50 "$1,301.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317183 PHYSICIAN FEE - SURGERY PF-PART REMOVAL 1ST METATARSAL EACH 28111 $843.00 960 $590.10 $421.50 $674.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317175 PHYSICIAN FEE - SURGERY PF-PART REMOVAL 5TH METATARSAL EACH 28110 $777.00 960 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313364 PHYSICIAN FEE - SURGERY PF-PART REMOVAL HIP BONE DEEP EACH 27071 "$2,657.00 " 960 "$1,859.90 " "$1,328.50 " "$2,125.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317191 PHYSICIAN FEE - SURGERY PF-PART REMOVAL METATARSAL 2-4 EACH 28112 $830.00 960 $581.00 $415.00 $664.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317258 PHYSICIAN FEE - SURGERY PF-PART REMOVAL OF ANKLE/HEEL EACH 28120 "$1,326.00 " 960 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317274 PHYSICIAN FEE - SURGERY PF-PART REMOVAL TOE - PHALANX EACH 28124 $880.00 960 $616.00 $440.00 $704.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317282 PHYSICIAN FEE - SURGERY PF-PART REMOVAL TOE-PHALANGEAL EACH 28126 $666.00 960 $466.20 $333.00 $532.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313356 PHYSICIAN FEE - SURGERY PF-PART REMOVE HIP BONE SUPER EACH 27070 "$2,412.00 " 960 "$1,688.40 " "$1,206.00 " "$1,929.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317266 PHYSICIAN FEE - SURGERY PF-PART REMOVL FT BONE TAR/MET EACH 28122 "$1,165.00 " 960 $815.50 $582.50 $932.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317639 PHYSICIAN FEE - SURGERY PF-PART REMVL FT BONE-MET HEAD EACH 28288 "$1,153.00 " 960 $807.10 $576.50 $922.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318538 PHYSICIAN FEE - SURGERY PF-PARTIAL AMPUTATION OF TOE EACH 28825 $462.00 960 $323.40 $231.00 $369.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330053 PHYSICIAN FEE - SURGERY PF-PARTIAL EXCISION OF LIP EACH 40500 $983.00 960 $688.10 $491.50 $786.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330061 PHYSICIAN FEE - SURGERY PF-PARTIAL EXCISION OF LIP EACH 40510 $935.00 960 $654.50 $467.50 $748.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330079 PHYSICIAN FEE - SURGERY PF-PARTIAL EXCISION OF LIP EACH 40520 $958.00 960 $670.60 $479.00 $766.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313570 PHYSICIAN FEE - SURGERY PF-PARTIAL HIP REPLACEMENT EACH 27125 "$3,115.00 " 960 "$2,180.50 " "$1,557.50 " "$2,492.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343908 PHYSICIAN FEE - SURGERY PF-PARTIAL HYSTERECTOMY EACH 58180 "$2,634.00 " 960 "$1,843.80 " "$1,317.00 " "$2,107.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303621 PHYSICIAN FEE - SURGERY PF-PARTIAL MASTECTOMY EACH 19301 "$1,865.00 " 960 "$1,305.50 " $932.50 "$1,492.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334683 PHYSICIAN FEE - SURGERY PF-PARTIAL PROCTECTOMY EACH 45113 "$4,958.00 " 960 "$3,470.60 " "$2,479.00 " "$3,966.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334741 PHYSICIAN FEE - SURGERY PF-PARTIAL PROCTECTOMY EACH 45123 "$3,018.00 " 960 "$2,112.60 " "$1,509.00 " "$2,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322001 PHYSICIAN FEE - SURGERY PF-PARTIAL RELEASE OF LUNG EACH 32225 "$2,780.00 " 960 "$1,946.00 " "$1,390.00 " "$2,224.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307747 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL COLLAR BONE EACH 23120 "$1,621.00 " 960 "$1,134.70 " $810.50 "$1,296.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336209 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL DONOR LIVER EACH 47140 "$10,134.00 " 960 "$7,093.80 " "$5,067.00 " "$8,107.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336217 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL DONOR LIVER EACH 47141 "$12,115.00 " 960 "$8,480.50 " "$6,057.50 " "$9,692.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336225 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL DONOR LIVER EACH 47142 "$13,346.00 " 960 "$9,342.20 " "$6,673.00 " "$10,676.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331846 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL ESOPHAGUS EACH 43116 "$10,230.00 " 960 "$7,161.00 " "$5,115.00 " "$8,184.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331853 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL ESOPHAGUS EACH 43117 "$9,151.00 " 960 "$6,405.70 " "$4,575.50 " "$7,320.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331861 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL ESOPHAGUS EACH 43118 "$10,202.00 " 960 "$7,141.40 " "$5,101.00 " "$8,161.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331879 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL ESOPHAGUS EACH 43121 "$8,038.00 " 960 "$5,626.60 " "$4,019.00 " "$6,430.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331887 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL ESOPHAGUS EACH 43122 "$7,231.00 " 960 "$5,061.70 " "$3,615.50 " "$5,784.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331895 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL ESOPHAGUS EACH 43123 "$12,671.00 " 960 "$8,869.70 " "$6,335.50 " "$10,136.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351950 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL EYE FLUID EACH 67005 "$1,219.00 " 960 $853.30 $609.50 $975.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351968 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL EYE FLUID EACH 67010 "$1,396.00 " 960 $977.20 $698.00 "$1,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311665 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL FINGER BONE EACH 26235 "$1,355.00 " 960 $948.50 $677.50 "$1,084.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311673 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL FINGER BONE EACH 26236 "$1,216.00 " 960 $851.20 $608.00 $972.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317019 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL FOOT FASCIA EACH 28060 $955.00 960 $668.50 $477.50 $764.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311657 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL HAND BONE EACH 26230 "$1,374.00 " 960 $961.80 $687.00 "$1,099.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322845 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL HEART SAC EACH 33030 "$5,594.00 " 960 "$3,915.80 " "$2,797.00 " "$4,475.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322852 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL HEART SAC EACH 33031 "$6,918.00 " 960 "$4,842.60 " "$3,459.00 " "$5,534.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314529 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL LEG BONE(S) EACH 27360 "$2,468.00 " 960 "$1,727.60 " "$1,234.00 " "$1,974.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308828 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF ARM BONE EACH 24140 "$1,934.00 " 960 "$1,353.80 " $967.00 "$1,547.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339609 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF BLADDER EACH 51550 "$2,581.00 " 960 "$1,806.70 " "$1,290.50 " "$2,064.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339617 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF BLADDER EACH 51555 "$3,358.00 " 960 "$2,350.60 " "$1,679.00 " "$2,686.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333727 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF COLON EACH 44143 "$4,629.00 " 960 "$3,240.30 " "$2,314.50 " "$3,703.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333701 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF COLON EACH 44140 "$3,771.00 " 960 "$2,639.70 " "$1,885.50 " "$3,016.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333719 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF COLON EACH 44141 "$5,075.00 " 960 "$3,552.50 " "$2,537.50 " "$4,060.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333735 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF COLON EACH 44144 "$4,937.00 " 960 "$3,455.90 " "$2,468.50 " "$3,949.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333743 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF COLON EACH 44145 "$4,584.00 " 960 "$3,208.80 " "$2,292.00 " "$3,667.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333750 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF COLON EACH 44146 "$5,825.00 " 960 "$4,077.50 " "$2,912.50 " "$4,660.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333768 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF COLON EACH 44147 "$5,416.00 " 960 "$3,791.20 " "$2,708.00 " "$4,332.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308844 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF ELBOW EACH 24147 "$1,722.00 " 960 "$1,205.40 " $861.00 "$1,377.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315831 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF FIBULA EACH 27641 "$1,772.00 " 960 "$1,240.40 " $886.00 "$1,417.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342876 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF HYMEN EACH 56700 $550.00 960 $385.00 $275.00 $440.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338346 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF KIDNEY EACH 50240 "$3,532.00 " 960 "$2,472.40 " "$1,766.00 " "$2,825.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320773 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LARYNX EACH 31367 "$5,781.00 " 960 "$4,046.70 " "$2,890.50 " "$4,624.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320781 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LARYNX EACH 31368 "$6,393.00 " 960 "$4,475.10 " "$3,196.50 " "$5,114.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320799 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LARYNX EACH 31370 "$5,415.00 " 960 "$3,790.50 " "$2,707.50 " "$4,332.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320807 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LARYNX EACH 31375 "$5,146.00 " 960 "$3,602.20 " "$2,573.00 " "$4,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320815 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LARYNX EACH 31380 "$5,074.00 " 960 "$3,551.80 " "$2,537.00 " "$4,059.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320823 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LARYNX EACH 31382 "$5,561.00 " 960 "$3,892.70 " "$2,780.50 " "$4,448.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330103 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LIP EACH 40530 "$1,094.00 " 960 $765.80 $547.00 $875.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336142 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LIVER EACH 47120 "$6,592.00 " 960 "$4,614.40 " "$3,296.00 " "$5,273.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336167 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LIVER EACH 47125 "$8,715.00 " 960 "$6,100.50 " "$4,357.50 " "$6,972.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336175 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LIVER EACH 47130 "$9,359.00 " 960 "$6,551.30 " "$4,679.50 " "$7,487.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322084 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF LUNG EACH 32480 "$4,140.00 " 960 "$2,898.00 " "$2,070.00 " "$3,312.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319957 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF NOSE EACH 30150 "$2,134.00 " 960 "$1,493.80 " "$1,067.00 " "$1,707.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344690 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF OVARY(S) EACH 58920 "$1,955.00 " 960 "$1,368.50 " $977.50 "$1,564.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336928 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF PANCREAS EACH 48140 "$4,433.00 " 960 "$3,103.10 " "$2,216.50 " "$3,546.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336936 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF PANCREAS EACH 48145 "$4,640.00 " 960 "$3,248.00 " "$2,320.00 " "$3,712.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336969 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF PANCREAS EACH 48150 "$8,815.00 " 960 "$6,170.50 " "$4,407.50 " "$7,052.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341415 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF PENIS EACH 54120 "$1,684.00 " 960 "$1,178.80 " $842.00 "$1,347.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331622 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF PHARYNX EACH 42890 "$3,760.00 " 960 "$2,632.00 " "$1,880.00 " "$3,008.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310089 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF RADIUS EACH 25151 "$1,605.00 " 960 "$1,123.50 " $802.50 "$1,284.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308836 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF RADIUS EACH 24145 "$1,643.00 " 960 "$1,150.10 " $821.50 "$1,314.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310121 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF RADIUS EACH 25230 "$1,191.00 " 960 $833.70 $595.50 $952.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334667 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF RECTUM EACH 45111 "$2,998.00 " 960 "$2,098.60 " "$1,499.00 " "$2,398.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334691 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF RECTUM EACH 45114 "$5,162.00 " 960 "$3,613.40 " "$2,581.00 " "$4,129.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334709 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF RECTUM EACH 45116 "$4,115.00 " 960 "$2,880.50 " "$2,057.50 " "$3,292.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306400 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF RIB EACH 21600 "$1,567.00 " 960 "$1,096.90 " $783.50 "$1,253.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306418 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF RIB EACH 21610 "$3,606.00 " 960 "$2,524.20 " "$1,803.00 " "$2,884.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307895 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF SCAPULA EACH 23190 "$1,589.00 " 960 "$1,112.30 " $794.50 "$1,271.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306442 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF STERNUM EACH 21620 "$1,401.00 " 960 $980.70 $700.50 "$1,120.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345515 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF THYROID EACH 60220 "$1,945.00 " 960 "$1,361.50 " $972.50 "$1,556.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345523 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF THYROID EACH 60225 "$2,579.00 " 960 "$1,805.30 " "$1,289.50 " "$2,063.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315823 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF TIBIA EACH 27640 "$2,272.00 " 960 "$1,590.40 " "$1,136.00 " "$1,817.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330608 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF TONGUE EACH 41120 "$2,773.00 " 960 "$1,941.10 " "$1,386.50 " "$2,218.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330616 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF TONGUE EACH 41130 "$3,454.00 " 960 "$2,417.80 " "$1,727.00 " "$2,763.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309990 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF ULNA EACH 25119 "$1,387.00 " 960 $970.90 $693.50 "$1,109.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310071 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF ULNA EACH 25150 "$1,560.00 " 960 "$1,092.00 " $780.00 "$1,248.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310139 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF ULNA EACH 25240 "$1,185.00 " 960 $829.50 $592.50 $948.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342785 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL OF VULVA EACH 56620 "$1,586.00 " 960 "$1,110.20 " $793.00 "$1,268.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353303 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL TEAR GLAND EACH 68505 "$2,705.00 " 960 "$1,893.50 " "$1,352.50 " "$2,164.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317324 PHYSICIAN FEE - SURGERY PF-PARTIAL REMOVAL TOE-PHALANX EACH 28153 $695.00 960 $486.50 $347.50 $556.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345507 PHYSICIAN FEE - SURGERY PF-PARTIAL THYROID EXCISION EACH 60212 "$2,909.00 " 960 "$2,036.30 " "$1,454.50 " "$2,327.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302219 PHYSICIAN FEE - SURGERY PF-PEDCLE FH/CH/M/N/AX/G/H/F EACH 15574 "$1,984.00 " 960 "$1,388.80 " $992.00 "$1,587.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302227 PHYSICIAN FEE - SURGERY PF-PEDICLE E/N/E/L/NTRORAL EACH 15576 "$1,708.00 " 960 "$1,195.60 " $854.00 "$1,366.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357239 PHYSICIAN FEE - SURGERY PF-PELV RING FX TREAT INT FIX EACH G0414 "$2,273.00 " 960 "$1,591.10 " "$1,136.50 " "$1,818.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343510 PHYSICIAN FEE - SURGERY PF-PELVIC EXAMINATION EACH 57410 $289.00 960 $202.30 $144.50 $231.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334758 PHYSICIAN FEE - SURGERY PF-PELVIC EXENTERATION EACH 45126 "$7,428.00 " 960 "$5,199.60 " "$3,714.00 " "$5,942.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357221 PHYSICIAN FEE - SURGERY PF-PELVIC RING FRACTURE UNI/BI EACH G0413 "$2,932.00 " 960 "$2,052.40 " "$1,466.00 " "$2,345.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357858 PHYSICIAN FEE - SURGERY PF-PELVIS/HIP JOINT SURG NOS EACH 27299 "$3,693.00 " 960 "$2,585.10 " "$1,846.50 " "$2,954.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341563 PHYSICIAN FEE - SURGERY PF-PENILE INJECTION EACH 54235 $196.00 960 $137.20 $98.00 $156.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329402 PHYSICIAN FEE - SURGERY PF-PENILE VENOUS OCCLUSION EACH 37790 "$1,292.00 " 960 $904.40 $646.00 "$1,033.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341753 PHYSICIAN FEE - SURGERY PF-PENIS PLASTIC SURGERY EACH 54360 "$1,916.00 " 960 "$1,341.20 " $958.00 "$1,532.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341571 PHYSICIAN FEE - SURGERY PF-PENIS STUDY EACH 54240 $113.00 960 $79.10 $56.50 $90.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341589 PHYSICIAN FEE - SURGERY PF-PENIS STUDY EACH 54250 $38.00 960 $26.60 $19.00 $30.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313851 PHYSICIAN FEE - SURGERY PF-PERC FIX PELVIC RING FRACT EACH 27216 "$2,359.00 " 960 "$1,651.30 " "$1,179.50 " "$1,887.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357171 PHYSICIAN FEE - SURGERY PF-PERC ISLET CELLTRANS EACH G0341 $828.00 960 $579.60 $414.00 $662.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338916 PHYSICIAN FEE - SURGERY PF-PERC RF ABLATE RENAL TUMOR EACH 50592 $887.00 960 $620.90 $443.50 $709.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337223 PHYSICIAN FEE - SURGERY PF-PERITONEAL LAVAGE EACH 49084 $300.00 960 $210.00 $150.00 $240.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357049 PHYSICIAN FEE - SURGERY PF-PERQ ABLTJ LVR CRYOABLATION EACH 47383 "$1,162.00 " 960 $813.40 $581.00 $929.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354517 PHYSICIAN FEE - SURGERY PF-PERQ CERVICOTHORACIC INJECT EACH 22510 "$1,158.00 " 960 $810.60 $579.00 $926.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359557 PHYSICIAN FEE - SURGERY PF-PERQ CLSR TCAT L ATR APNDGE EACH 33340 "$2,155.00 " 960 "$1,508.50 " "$1,077.50 " "$1,724.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303563 PHYSICIAN FEE - SURGERY PF-PERQ DEV BREAST 1 US IMAGE EACH 19285 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354434 PHYSICIAN FEE - SURGERY PF-PERQ DEV BREAST 1ST MR GD EACH 19287 $325.00 960 $227.50 $162.50 $260.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354418 PHYSICIAN FEE - SURGERY PF-PERQ DEV BREAST 1ST STRTCTC EACH 19283 $260.00 960 $182.00 $130.00 $208.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354442 PHYSICIAN FEE - SURGERY PF-PERQ DEV BREAST ADD MR GD EACH 19288 $162.00 960 $113.40 $81.00 $129.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354426 PHYSICIAN FEE - SURGERY PF-PERQ DEV BREAST ADD STRTCTC EACH 19284 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303571 PHYSICIAN FEE - SURGERY PF-PERQ DEV BREAST ASS US IMAG EACH 19286 $111.00 960 $77.70 $55.50 $88.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359300 PHYSICIAN FEE - SURGERY PF-PERQ DEV SOFT TISS 1ST IMAG EACH 10035 $219.00 960 $153.30 $109.50 $175.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359318 PHYSICIAN FEE - SURGERY PF-PERQ DEV SOFT TISS ADD IMAG EACH 10036 $112.00 960 $78.40 $56.00 $89.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355837 PHYSICIAN FEE - SURGERY PF-PERQ IMP ELECT SACRL N BI EACH 64561 $812.00 960 $568.40 $406.00 $649.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355829 PHYSICIAN FEE - SURGERY PF-PERQ IMP ELECTR SACRL N LT EACH 64561 $812.00 960 $568.40 $406.00 $649.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355811 PHYSICIAN FEE - SURGERY PF-PERQ IMP ELECTR SACRL N RT EACH 64561 $812.00 960 $568.40 $406.00 $649.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358617 PHYSICIAN FEE - SURGERY PF-PERQ LAMOT/LAM CRV/THRC EACH 34711 $831.00 960 $581.70 $415.50 $664.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306988 PHYSICIAN FEE - SURGERY PF-PERQ LUMBOSACRAL INJECTION EACH 22511 "$1,090.00 " 960 $763.00 $545.00 $872.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361272 PHYSICIAN FEE - SURGERY PF-PERQ P-ART REVSC 1 ABNOR BI EACH 33903 "$2,353.00 " 960 "$1,647.10 " "$1,176.50 " "$1,882.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361264 PHYSICIAN FEE - SURGERY PF-PERQ P-ART REVSC 1 ABNOR UN EACH 33902 "$1,997.00 " 960 "$1,397.90 " $998.50 "$1,597.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361256 PHYSICIAN FEE - SURGERY PF-PERQ P-ART REVSC 1 NM NT BI EACH 33901 "$2,069.00 " 960 "$1,448.30 " "$1,034.50 " "$1,655.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361249 PHYSICIAN FEE - SURGERY PF-PERQ P-ART REVSC 1 NM NT UN EACH 33900 "$1,574.00 " 960 "$1,101.80 " $787.00 "$1,259.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361280 PHYSICIAN FEE - SURGERY PF-PERQ P-ART REVSC EACH ADDL EACH 33904 $792.00 960 $554.40 $396.00 $633.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322787 PHYSICIAN FEE - SURGERY PF-PERQ RF ABLATE TX PUL TUMOR EACH 32998 "$1,139.00 " 960 $797.30 $569.50 $911.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502496 PHYSICIAN FEE - SURGERY PF-PERQ TRLUM ANGP NT/RECR COA EACH 33897 "$1,611.00 " 960 "$1,127.70 " $805.50 "$1,288.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354533 PHYSICIAN FEE - SURGERY PF-PERQ VERTEBRAL AUGMENTATION EACH 22513 "$1,396.00 " 960 $977.20 $698.00 "$1,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354541 PHYSICIAN FEE - SURGERY PF-PERQ VERTEBRAL AUGMENTATION EACH 22514 "$1,300.00 " 960 $910.00 $650.00 "$1,040.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354558 PHYSICIAN FEE - SURGERY PF-PERQ VERTEBRAL AUGMENTATION EACH 22515 $601.00 960 $420.70 $300.50 $480.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329360 PHYSICIAN FEE - SURGERY PF-PHLEB VEINS - EXTREM 20+ EACH 37766 $922.00 960 $645.40 $461.00 $737.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328107 PHYSICIAN FEE - SURGERY PF-PHOTOPHERESIS EACH 36522 $244.00 960 $170.80 $122.00 $195.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345929 PHYSICIAN FEE - SURGERY PF-PIERCE SKULL & EXPLORE EACH 61250 "$2,602.00 " 960 "$1,821.40 " "$1,301.00 " "$2,081.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345937 PHYSICIAN FEE - SURGERY PF-PIERCE SKULL & EXPLORE EACH 61253 "$2,986.00 " 960 "$2,090.20 " "$1,493.00 " "$2,388.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345887 PHYSICIAN FEE - SURGERY PF-PIERCE SKULL & REMOVE CLOT EACH 61154 "$3,829.00 " 960 "$2,680.30 " "$1,914.50 " "$3,063.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345853 PHYSICIAN FEE - SURGERY PF-PIERCE SKULL FOR BIOPSY EACH 61140 "$3,820.00 " 960 "$2,674.00 " "$1,910.00 " "$3,056.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345861 PHYSICIAN FEE - SURGERY PF-PIERCE SKULL FOR DRAINAGE EACH 61150 "$4,069.00 " 960 "$2,848.30 " "$2,034.50 " "$3,255.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345879 PHYSICIAN FEE - SURGERY PF-PIERCE SKULL FOR DRAINAGE EACH 61151 "$2,986.00 " 960 "$2,090.20 " "$1,493.00 " "$2,388.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345895 PHYSICIAN FEE - SURGERY PF-PIERCE SKULL FOR DRAINAGE EACH 61156 "$3,736.00 " 960 "$2,615.20 " "$1,868.00 " "$2,988.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345903 PHYSICIAN FEE - SURGERY PF-PIERCE SKULL IMPLANT DEVICE EACH 61210 "$1,112.00 " 960 $778.40 $556.00 $889.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312887 PHYSICIAN FEE - SURGERY PF-PIN FINGER DISLOCATION EACH 26776 "$1,234.00 " 960 $863.80 $617.00 $987.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312846 PHYSICIAN FEE - SURGERY PF-PIN FINGER FRACTURE EACH EACH 26756 "$1,163.00 " 960 $814.10 $581.50 $930.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312689 PHYSICIAN FEE - SURGERY PF-PIN HAND DISLOCATION EACH 26676 "$1,399.00 " 960 $979.30 $699.50 "$1,119.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312739 PHYSICIAN FEE - SURGERY PF-PIN KNUCKLE DISLOCATION EACH 26706 "$1,222.00 " 960 $855.40 $611.00 $977.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311020 PHYSICIAN FEE - SURGERY PF-PIN RADIOULNAR DISLOCATION EACH 25671 "$1,479.00 " 960 "$1,035.30 " $739.50 "$1,183.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310980 PHYSICIAN FEE - SURGERY PF-PIN ULNAR STYLOID FRACTURE EACH 25651 "$1,351.00 " 960 $945.70 $675.50 "$1,080.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303597 PHYSICIAN FEE - SURGERY PF-PLACE BREAST CATH FOR RAD EACH 19297 $266.00 960 $186.20 $133.00 $212.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303605 PHYSICIAN FEE - SURGERY PF-PLACE BREAST RAD TUBE/CATHS EACH 19298 $821.00 960 $574.70 $410.50 $656.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327646 PHYSICIAN FEE - SURGERY PF-PLACE CATH THORACIC AORTA EACH 36221 $557.00 960 $389.90 $278.50 $445.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327695 PHYSICIAN FEE - SURGERY PF-PLACE CATH VERTEBRAL ART EACH 36226 "$1,055.00 " 960 $738.50 $527.50 $844.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356959 PHYSICIAN FEE - SURGERY PF-PLACE CATH XTRNL CAROTID BI EACH 36227 $349.00 960 $244.30 $174.50 $279.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327596 PHYSICIAN FEE - SURGERY PF-PLACE CATHETER IN AORTA EACH 36200 $387.00 960 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327505 PHYSICIAN FEE - SURGERY PF-PLACE CATHETER IN ARTERY EACH 36013 $333.00 960 $233.10 $166.50 $266.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327604 PHYSICIAN FEE - SURGERY PF-PLACE CATHETER IN ARTERY EACH 36215 $564.00 960 $394.80 $282.00 $451.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327752 PHYSICIAN FEE - SURGERY PF-PLACE CATHETER IN ARTERY EACH 36248 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327471 PHYSICIAN FEE - SURGERY PF-PLACE CATHETER IN VEIN EACH 36010 $296.00 960 $207.20 $148.00 $236.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337603 PHYSICIAN FEE - SURGERY PF-PLACE CECOSTOMY TUBE PERC EACH 49442 $530.00 960 $371.00 $265.00 $424.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337595 PHYSICIAN FEE - SURGERY PF-PLACE DUOD/JEJ TUBE PERC EACH 49441 $639.00 960 $447.30 $319.50 $511.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332232 PHYSICIAN FEE - SURGERY PF-PLACE GASTROSTOMY TUBE EACH 43246 $536.00 960 $375.20 $268.00 $428.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333313 PHYSICIAN FEE - SURGERY PF-PLACE GASTROSTOMY TUBE EACH 43830 "$1,978.00 " 960 "$1,384.60 " $989.00 "$1,582.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333321 PHYSICIAN FEE - SURGERY PF-PLACE GASTROSTOMY TUBE EACH 43831 "$1,712.00 " 960 "$1,198.40 " $856.00 "$1,369.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333339 PHYSICIAN FEE - SURGERY PF-PLACE GASTROSTOMY TUBE EACH 43832 "$2,967.00 " 960 "$2,076.90 " "$1,483.50 " "$2,373.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304157 PHYSICIAN FEE - SURGERY PF-PLACE NDL MUSC/TIS FOR RT EACH 20555 $868.00 960 $607.60 $434.00 $694.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330509 PHYSICIAN FEE - SURGERY PF-PLACE NEEDLES H&N FOR RT EACH 41019 "$1,266.00 " 960 $886.20 $633.00 "$1,012.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342686 PHYSICIAN FEE - SURGERY PF-PLACE NEEDLES PELVIC FOR RT EACH 55920 "$1,196.00 " 960 $837.20 $598.00 $956.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303589 PHYSICIAN FEE - SURGERY PF-PLACE PO BREAST CATH RAD EACH 19296 $595.00 960 $416.50 $297.50 $476.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342678 PHYSICIAN FEE - SURGERY PF-PLACE RT DEVICE/MARKER PROS EACH 55876 $269.00 960 $188.30 $134.50 $215.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336829 PHYSICIAN FEE - SURGERY PF-PLACEMENT BILE DUCT SUPPORT EACH 47801 "$3,154.00 " 960 "$2,207.80 " "$1,577.00 " "$2,523.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336860 PHYSICIAN FEE - SURGERY PF-PLACEMENT OF DRAIN PANCREAS EACH 48001 "$6,557.00 " 960 "$4,589.90 " "$3,278.50 " "$5,245.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335383 PHYSICIAN FEE - SURGERY PF-PLACEMENT OF SETON EACH 46020 $320.00 960 $224.00 $160.00 $256.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358898 PHYSICIAN FEE - SURGERY PF-PLMT BILIARY DRAINAGE CATH EACH 47534 $948.00 960 $663.60 $474.00 $758.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360100 PHYSICIAN FEE - SURGERY PF-PLMT NEPHROURETERAL CATH EACH 50433 $656.00 960 $459.20 $328.00 $524.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303639 PHYSICIAN FEE - SURGERY PF-P-MASTECTOMY W/LN REMOVAL EACH 19302 "$2,562.00 " 960 "$1,793.40 " "$1,281.00 " "$2,049.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312432 PHYSICIAN FEE - SURGERY PF-POSITIONAL CHANGE OF FINGER EACH 26555 "$3,774.00 " 960 "$2,641.80 " "$1,887.00 " "$3,019.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338395 PHYSICIAN FEE - SURGERY PF-PREP CADAVER RENAL ALLOGRFT EACH 50323 $717.00 960 $501.90 $358.50 $573.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351232 PHYSICIAN FEE - SURGERY PF-PREP CORNEAL ENDO ALLOGRAFT EACH 65757 $188.00 960 $131.60 $94.00 $150.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334519 PHYSICIAN FEE - SURGERY PF-PREP DONOR INTESTINE/ARTERY EACH 44721 "$1,088.00 " 960 $761.60 $544.00 $870.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334501 PHYSICIAN FEE - SURGERY PF-PREP DONOR INTESTINE/VENOUS EACH 44720 $777.00 960 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336241 PHYSICIAN FEE - SURGERY PF-PREP DONOR LIVER 3-SEGMENT EACH 47144 "$1,432.00 " 960 "$1,002.40 " $716.00 "$1,145.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336258 PHYSICIAN FEE - SURGERY PF-PREP DONOR LIVER LOBE SPLIT EACH 47145 "$1,432.00 " 960 "$1,002.40 " $716.00 "$1,145.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336233 PHYSICIAN FEE - SURGERY PF-PREP DONOR LIVER WHOLE EACH 47143 "$1,432.00 " 960 "$1,002.40 " $716.00 "$1,145.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336274 PHYSICIAN FEE - SURGERY PF-PREP DONOR LIVER/ARTERIAL EACH 47147 "$1,084.00 " 960 $758.80 $542.00 $867.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336266 PHYSICIAN FEE - SURGERY PF-PREP DONOR LIVER/VENOUS EACH 47146 $930.00 960 $651.00 $465.00 $744.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337090 PHYSICIAN FEE - SURGERY PF-PREP DONOR PANCREAS EACH 48551 $661.00 960 $462.70 $330.50 $528.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337108 PHYSICIAN FEE - SURGERY PF-PREP DONOR PANCREAS/VENOUS EACH 48552 $671.00 960 $469.70 $335.50 $536.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338403 PHYSICIAN FEE - SURGERY PF-PREP DONOR RENAL GRAFT EACH 50325 $422.00 960 $295.40 $211.00 $337.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338429 PHYSICIAN FEE - SURGERY PF-PREP RENAL GRAFT/ARTERIAL EACH 50328 $537.00 960 $375.90 $268.50 $429.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338437 PHYSICIAN FEE - SURGERY PF-PREP RENAL GRAFT/URETERAL EACH 50329 $507.00 960 $354.90 $253.50 $405.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338411 PHYSICIAN FEE - SURGERY PF-PREP RENAL GRAFT/VENOUS EACH 50327 $612.00 960 $428.40 $306.00 $489.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358427 PHYSICIAN FEE - SURGERY PF-PREP TUM CAV IORT PRTL MAST EACH 19294 $467.00 960 $326.90 $233.50 $373.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339724 PHYSICIAN FEE - SURGERY PF-PREPARATION BLADDER XRAY EACH 51605 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331093 PHYSICIAN FEE - SURGERY PF-PREPARATION PALATE MOLD EACH 42280 $284.00 960 $198.80 $142.00 $227.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325210 PHYSICIAN FEE - SURGERY PF-PREPARE DONOR HEART EACH 33944 $821.00 960 $574.70 $410.50 $656.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325194 PHYSICIAN FEE - SURGERY PF-PREPARE DONOR HEART/LUNG EACH 33933 "$1,165.00 " 960 $815.50 $582.50 $932.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322712 PHYSICIAN FEE - SURGERY PF-PREPARE DONOR LUNG DOUBLE EACH 32856 "$1,017.00 " 960 $711.90 $508.50 $813.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322704 PHYSICIAN FEE - SURGERY PF-PREPARE DONOR LUNG SINGLE EACH 32855 $842.00 960 $589.40 $421.00 $673.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304959 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21076 "$1,856.00 " 960 "$1,299.20 " $928.00 "$1,484.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304967 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21077 "$4,563.00 " 960 "$3,194.10 " "$2,281.50 " "$3,650.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304975 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21079 "$3,066.00 " 960 "$2,146.20 " "$1,533.00 " "$2,452.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304983 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21080 "$3,458.00 " 960 "$2,420.60 " "$1,729.00 " "$2,766.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304991 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21081 "$3,176.00 " 960 "$2,223.20 " "$1,588.00 " "$2,540.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305006 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21082 "$2,926.00 " 960 "$2,048.20 " "$1,463.00 " "$2,340.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305014 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21083 "$2,704.00 " 960 "$1,892.80 " "$1,352.00 " "$2,163.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305022 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21084 "$3,130.00 " 960 "$2,191.00 " "$1,565.00 " "$2,504.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305030 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21085 "$1,273.00 " 960 $891.10 $636.50 "$1,018.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305048 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21086 "$3,362.00 " 960 "$2,353.40 " "$1,681.00 " "$2,689.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305055 PHYSICIAN FEE - SURGERY PF-PREPARE FACE/ORL PROSTHESIS EACH 21087 "$3,362.00 " 960 "$2,353.40 " "$1,681.00 " "$2,689.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323645 PHYSICIAN FEE - SURGERY PF-PREPARE HEART-AORTA CONDUIT EACH 33404 "$4,850.00 " 960 "$3,395.00 " "$2,425.00 " "$3,880.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341548 PHYSICIAN FEE - SURGERY PF-PREPARE PENIS STUDY EACH 54230 $211.00 960 $147.70 $105.50 $168.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342330 PHYSICIAN FEE - SURGERY PF-PREPARE SPERM DUCT X-RAY EACH 55300 $492.00 960 $344.40 $246.00 $393.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341936 PHYSICIAN FEE - SURGERY PF-PREPUTIAL STRETCHING EACH 54450 $152.00 960 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307093 PHYSICIAN FEE - SURGERY PF-PRESCRL FUSE W/ INSTR L5/S1 EACH 22586 "$6,109.00 " 960 "$4,276.30 " "$3,054.50 " "$4,887.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332869 PHYSICIAN FEE - SURGERY PF-PRESSURE TX ESOPHAGUS EACH 43460 $556.00 960 $389.20 $278.00 $444.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353485 PHYSICIAN FEE - SURGERY PF-PROBE NASOLACRIMAL DUCT EACH 68815 $569.00 960 $398.30 $284.50 $455.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353493 PHYSICIAN FEE - SURGERY PF-PROBE NL DUCT W/BALLOON EACH 68816 $403.00 960 $282.10 $201.50 $322.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334923 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY ABLATE EACH 45320 $295.00 960 $206.50 $147.50 $236.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334915 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY BLEED EACH 45317 $300.00 960 $210.00 $150.00 $240.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334857 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY DILATE EACH 45303 $233.00 960 $163.10 $116.50 $186.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334840 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY DX EACH 45300 $131.00 960 $91.70 $65.50 $104.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334873 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY FB EACH 45307 $283.00 960 $198.10 $141.50 $226.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334881 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY REMOVAL EACH 45308 $239.00 960 $167.30 $119.50 $191.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334899 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY REMOVAL EACH 45309 $253.00 960 $177.10 $126.50 $202.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334907 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY REMOVAL EACH 45315 $299.00 960 $209.30 $149.50 $239.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334931 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY VOLVUL EACH 45321 $292.00 960 $204.40 $146.00 $233.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334865 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY W/BX EACH 45305 $198.00 960 $138.60 $99.00 $158.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334949 PHYSICIAN FEE - SURGERY PF-PROCTOSIGMOIDOSCOPY W/STENT EACH 45327 $330.00 960 $231.00 $165.00 $264.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357254 PHYSICIAN FEE - SURGERY "PF-PROSTATE BIOPSY, ANY MTHD " EACH G0416 $431.00 960 $301.70 $215.50 $344.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340680 PHYSICIAN FEE - SURGERY PF-PROSTATE LASER ENUCLEATION EACH 52649 "$2,189.00 " 960 "$1,532.30 " "$1,094.50 " "$1,751.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342488 PHYSICIAN FEE - SURGERY PF-PROSTATE SATURATION SAMPL EACH 55706 $996.00 960 $697.20 $498.00 $796.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340631 PHYSICIAN FEE - SURGERY PF-PROSTATECTOMY (TURP) EACH 52601 "$1,934.00 " 960 "$1,353.80 " $967.00 "$1,547.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341225 PHYSICIAN FEE - SURGERY PF-PROSTATIC MICROWAVE THERMTX EACH 53850 $945.00 960 $661.50 $472.50 $756.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341233 PHYSICIAN FEE - SURGERY PF-PROSTATIC RF THERMOTX EACH 53852 "$1,014.00 " 960 $709.80 $507.00 $811.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337744 PHYSICIAN FEE - SURGERY PF-PRP I/HERN INIT BLOCK >5 YR EACH 49507 "$1,662.00 " 960 "$1,163.40 " $831.00 "$1,329.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337736 PHYSICIAN FEE - SURGERY PF-PRP I/HERN INIT REDUC >5 YR EACH 49505 "$1,479.00 " 960 "$1,035.30 " $739.50 "$1,183.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361306 PHYSICIAN FEE - SURGERY PF-PRQ AV FSTL CRT UXTR SEP AC EACH 36837 "$1,226.00 " 960 $858.20 $613.00 $980.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361298 PHYSICIAN FEE - SURGERY PF-PRQ AV FSTL CRTJ UXTR 1 ACS EACH 36836 $944.00 960 $660.80 $472.00 $755.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359599 PHYSICIAN FEE - SURGERY PF-PRTL EXCHANGE TRANSFUSE NB EACH 36456 $250.00 960 $175.00 $125.00 $200.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359136 PHYSICIAN FEE - SURGERY PF-PUNCH SKIN BIOPSY 1ST EACH 11104 $124.00 960 $86.80 $62.00 $99.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359144 PHYSICIAN FEE - SURGERY PF-PUNCH SKIN BIOPSY ADDL EACH 11105 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321318 PHYSICIAN FEE - SURGERY PF-PUNCTURE/CLEAR WINDPIPE EACH 31612 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358740 PHYSICIAN FEE - SURGERY PF-PX EXTRAOCULAR MUSC NOS EACH 43287 "$9,995.00 " 960 "$6,996.50 " "$4,997.50 " "$7,996.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308851 PHYSICIAN FEE - SURGERY PF-RADICAL RESECTION OF ELBOW EACH 24149 "$3,235.00 " 960 "$2,264.50 " "$1,617.50 " "$2,588.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310378 PHYSICIAN FEE - SURGERY PF-REALIGNMENT OF HAND EACH 25335 "$2,604.00 " 960 "$1,822.80 " "$1,302.00 " "$2,083.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314990 PHYSICIAN FEE - SURGERY PF-REALIGNMENT OF KNEE EACH 27455 "$2,642.00 " 960 "$1,849.40 " "$1,321.00 " "$2,113.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315005 PHYSICIAN FEE - SURGERY PF-REALIGNMENT OF KNEE EACH 27457 "$2,597.00 " 960 "$1,817.90 " "$1,298.50 " "$2,077.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316169 PHYSICIAN FEE - SURGERY PF-REALIGNMENT OF LOWER LEG EACH 27712 "$3,037.00 " 960 "$2,125.90 " "$1,518.50 " "$2,429.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311954 PHYSICIAN FEE - SURGERY PF-REALIGNMENT OF TENDONS EACH 26437 "$1,785.00 " 960 "$1,249.50 " $892.50 "$1,428.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314982 PHYSICIAN FEE - SURGERY PF-REALIGNMENT OF THIGH BONE EACH 27454 "$3,563.00 " 960 "$2,494.10 " "$1,781.50 " "$2,850.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353964 PHYSICIAN FEE - SURGERY PF-REBUILD EARDRUM STRUCTURES EACH 69632 "$2,866.00 " 960 "$2,006.20 " "$1,433.00 " "$2,292.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353972 PHYSICIAN FEE - SURGERY PF-REBUILD EARDRUM STRUCTURES EACH 69633 "$2,797.00 " 960 "$1,957.90 " "$1,398.50 " "$2,237.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353998 PHYSICIAN FEE - SURGERY PF-REBUILD EARDRUM STRUCTURES EACH 69636 "$3,713.00 " 960 "$2,599.10 " "$1,856.50 " "$2,970.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354004 PHYSICIAN FEE - SURGERY PF-REBUILD EARDRUM STRUCTURES EACH 69637 "$3,697.00 " 960 "$2,587.90 " "$1,848.50 " "$2,957.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353691 PHYSICIAN FEE - SURGERY PF-REBUILD OUTER EAR CANAL EACH 69310 "$2,939.00 " 960 "$2,057.30 " "$1,469.50 " "$2,351.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353709 PHYSICIAN FEE - SURGERY PF-REBUILD OUTER EAR CANAL EACH 69320 "$4,112.00 " 960 "$2,878.40 " "$2,056.00 " "$3,289.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326325 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35311 "$4,316.00 " 960 "$3,021.20 " "$2,158.00 " "$3,452.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326267 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35301 "$3,180.00 " 960 "$2,226.00 " "$1,590.00 " "$2,544.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326275 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35302 "$3,144.00 " 960 "$2,200.80 " "$1,572.00 " "$2,515.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326283 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35303 "$3,452.00 " 960 "$2,416.40 " "$1,726.00 " "$2,761.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326291 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35304 "$3,595.00 " 960 "$2,516.50 " "$1,797.50 " "$2,876.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326309 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35305 "$3,457.00 " 960 "$2,419.90 " "$1,728.50 " "$2,765.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326317 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35306 "$1,261.00 " 960 $882.70 $630.50 "$1,008.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326333 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35321 "$2,523.00 " 960 "$1,766.10 " "$1,261.50 " "$2,018.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326341 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35331 "$4,094.00 " 960 "$2,865.80 " "$2,047.00 " "$3,275.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326358 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35341 "$3,897.00 " 960 "$2,727.90 " "$1,948.50 " "$3,117.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326366 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35351 "$3,619.00 " 960 "$2,533.30 " "$1,809.50 " "$2,895.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326374 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35355 "$2,896.00 " 960 "$2,027.20 " "$1,448.00 " "$2,316.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326382 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35361 "$4,311.00 " 960 "$3,017.70 " "$2,155.50 " "$3,448.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326390 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35363 "$4,596.00 " 960 "$3,217.20 " "$2,298.00 " "$3,676.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326408 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35371 "$2,288.00 " 960 "$1,601.60 " "$1,144.00 " "$1,830.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326416 PHYSICIAN FEE - SURGERY PF-RECHANNELING OF ARTERY EACH 35372 "$2,746.00 " 960 "$1,922.20 " "$1,373.00 " "$2,196.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305428 PHYSICIAN FEE - SURGERY PF-RECONST LWR JAW W/FIXATION EACH 21196 "$3,720.00 " 960 "$2,604.00 " "$1,860.00 " "$2,976.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305402 PHYSICIAN FEE - SURGERY PF-RECONST LWR JAW W/GRAFT EACH 21194 "$3,706.00 " 960 "$2,594.20 " "$1,853.00 " "$2,964.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305394 PHYSICIAN FEE - SURGERY PF-RECONST LWR JAW W/O GRAFT EACH 21193 "$3,206.00 " 960 "$2,244.20 " "$1,603.00 " "$2,564.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305410 PHYSICIAN FEE - SURGERY PF-RECONST LWR JAW WO FIXATION EACH 21195 "$3,481.00 " 960 "$2,436.70 " "$1,740.50 " "$2,784.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305436 PHYSICIAN FEE - SURGERY PF-RECONSTR LWR JAW SEGMENT EACH 21198 "$2,663.00 " 960 "$1,864.10 " "$1,331.50 " "$2,130.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305444 PHYSICIAN FEE - SURGERY PF-RECONSTR LWR JAW W/ADVANCE EACH 21199 "$2,657.00 " 960 "$1,859.90 " "$1,328.50 " "$2,125.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316102 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ANKLE JOINT EACH 27702 "$2,629.00 " 960 "$1,840.30 " "$1,314.50 " "$2,103.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321730 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT BRONCHUS EACH 31775 "$3,926.00 " 960 "$2,748.20 " "$1,963.00 " "$3,140.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317910 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CLEFT FOOT EACH 28360 "$3,017.00 " 960 "$2,111.90 " "$1,508.50 " "$2,413.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330996 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CLEFT PALATE EACH 42200 "$2,504.00 " 960 "$1,752.80 " "$1,252.00 " "$2,003.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331002 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CLEFT PALATE EACH 42205 "$2,613.00 " 960 "$1,829.10 " "$1,306.50 " "$2,090.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331010 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CLEFT PALATE EACH 42210 "$2,912.00 " 960 "$2,038.40 " "$1,456.00 " "$2,329.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331028 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CLEFT PALATE EACH 42215 "$1,895.00 " 960 "$1,326.50 " $947.50 "$1,516.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331036 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CLEFT PALATE EACH 42220 "$1,559.00 " 960 "$1,091.30 " $779.50 "$1,247.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331044 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CLEFT PALATE EACH 42225 "$2,602.00 " 960 "$1,821.40 " "$1,301.00 " "$2,081.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305352 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CRANIAL BONE EACH 21182 "$5,741.00 " 960 "$4,018.70 " "$2,870.50 " "$4,592.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305360 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CRANIAL BONE EACH 21183 "$6,247.00 " 960 "$4,372.90 " "$3,123.50 " "$4,997.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305378 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT CRANIAL BONE EACH 21184 "$6,723.00 " 960 "$4,706.10 " "$3,361.50 " "$5,378.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309123 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ELBOW JOINT EACH 24360 "$2,490.00 " 960 "$1,743.00 " "$1,245.00 " "$1,992.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309131 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ELBOW JOINT EACH 24361 "$2,775.00 " 960 "$1,942.50 " "$1,387.50 " "$2,220.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309149 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ELBOW JOINT EACH 24362 "$2,925.00 " 960 "$2,047.50 " "$1,462.50 " "$2,340.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309065 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ELBOW LAT LIGMT EACH 24344 "$3,042.00 " 960 "$2,129.40 " "$1,521.00 " "$2,433.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309081 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ELBOW MED LIGMT EACH 24346 "$3,042.00 " 960 "$2,129.40 " "$1,521.00 " "$2,433.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305329 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ENTIRE FOREHEAD EACH 21179 "$4,122.00 " 960 "$2,885.40 " "$2,061.00 " "$3,297.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305337 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ENTIRE FOREHEAD EACH 21180 "$4,602.00 " 960 "$3,221.40 " "$2,301.00 " "$3,681.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312523 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT EXTRA FINGER EACH 26587 "$2,874.00 " 960 "$2,011.80 " "$1,437.00 " "$2,299.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353048 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT EYELID TO 2/3 EACH 67971 "$1,839.00 " 960 "$1,287.30 " $919.50 "$1,471.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353071 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT EYELID TOTAL EACH 67975 "$1,743.00 " 960 "$1,220.10 " $871.50 "$1,394.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312366 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT FINGER JOINT EACH 26545 "$1,972.00 " 960 "$1,380.40 " $986.00 "$1,577.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312382 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT FINGER JOINT EACH 26548 "$2,153.00 " 960 "$1,507.10 " "$1,076.50 " "$1,722.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309172 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT HEAD OF RADIUS EACH 24366 "$1,869.00 " 960 "$1,308.30 " $934.50 "$1,495.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309164 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT HEAD OF RADIUS EACH 24365 "$1,771.00 " 960 "$1,239.70 " $885.50 "$1,416.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322654 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT INJURED CHEST EACH 32820 "$3,733.00 " 960 "$2,613.10 " "$1,866.50 " "$2,986.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320849 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT LARYNX&PHARYNX EACH 31395 "$7,828.00 " 960 "$5,479.60 " "$3,914.00 " "$6,262.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330087 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT LIP WITH FLAP EACH 40525 "$1,487.00 " 960 "$1,040.90 " $743.50 "$1,189.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330095 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT LIP WITH FLAP EACH 40527 "$1,690.00 " 960 "$1,183.00 " $845.00 "$1,352.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305584 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT LOWER JAW BONE EACH 21247 "$4,116.00 " 960 "$2,881.20 " "$2,058.00 " "$3,292.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305618 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT LOWER JAW BONE EACH 21255 "$3,467.00 " 960 "$2,426.90 " "$1,733.50 " "$2,773.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305188 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21141 "$3,467.00 " 960 "$2,426.90 " "$1,733.50 " "$2,773.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305196 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21142 "$3,561.00 " 960 "$2,492.70 " "$1,780.50 " "$2,848.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305204 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21143 "$3,670.00 " 960 "$2,569.00 " "$1,835.00 " "$2,936.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305212 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21145 "$4,035.00 " 960 "$2,824.50 " "$2,017.50 " "$3,228.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305220 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21146 "$4,215.00 " 960 "$2,950.50 " "$2,107.50 " "$3,372.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305238 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21147 "$4,435.00 " 960 "$3,104.50 " "$2,217.50 " "$3,548.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305246 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21150 "$4,400.00 " 960 "$3,080.00 " "$2,200.00 " "$3,520.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305253 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21151 "$4,846.00 " 960 "$3,392.20 " "$2,423.00 " "$3,876.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305261 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21154 "$5,217.00 " 960 "$3,651.90 " "$2,608.50 " "$4,173.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305279 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21155 "$5,792.00 " 960 "$4,054.40 " "$2,896.00 " "$4,633.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305287 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21159 "$6,943.00 " 960 "$4,860.10 " "$3,471.50 " "$5,554.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305295 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT MIDFACE LEFORT EACH 21160 "$7,533.00 " 960 "$5,273.10 " "$3,766.50 " "$6,026.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305303 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ORBIT/FOREHEAD EACH 21172 "$6,309.00 " 960 "$4,416.30 " "$3,154.50 " "$5,047.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305311 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ORBIT/FOREHEAD EACH 21175 "$5,989.00 " 960 "$4,192.30 " "$2,994.50 " "$4,791.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308133 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT SHOULDER JOINT EACH 23470 "$3,289.00 " 960 "$2,302.30 " "$1,644.50 " "$2,631.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308141 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT SHOULDER JOINT EACH 23472 "$3,965.00 " 960 "$2,775.50 " "$1,982.50 " "$3,172.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310386 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT ULNA/RADIOULNAR EACH 25337 "$2,427.00 " 960 "$1,698.90 " "$1,213.50 " "$1,941.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305451 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT UPPER JAW BONE EACH 21206 "$2,534.00 " 960 "$1,773.80 " "$1,267.00 " "$2,027.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340946 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT URETHRA STAGE 1 EACH 53420 "$2,230.00 " 960 "$1,561.00 " "$1,115.00 " "$1,784.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340953 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT URETHRA STAGE 2 EACH 53425 "$2,482.00 " 960 "$1,737.40 " "$1,241.00 " "$1,985.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340979 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT URETHRA/BLADDER EACH 53431 "$3,054.00 " 960 "$2,137.80 " "$1,527.00 " "$2,443.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341746 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT URETHRA/PENIS EACH 54352 "$3,744.00 " 960 "$2,620.80 " "$1,872.00 " "$2,995.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325558 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT VENA CAVA EACH 34502 "$4,311.00 " 960 "$3,017.70 " "$2,155.50 " "$3,448.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321748 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT WINDPIPE EACH 31780 "$3,222.00 " 960 "$2,255.40 " "$1,611.00 " "$2,577.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321755 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT WINDPIPE EACH 31781 "$3,870.00 " 960 "$2,709.00 " "$1,935.00 " "$3,096.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310592 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT WRIST JOINT EACH 25441 "$2,587.00 " 960 "$1,810.90 " "$1,293.50 " "$2,069.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310600 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT WRIST JOINT EACH 25442 "$2,216.00 " 960 "$1,551.20 " "$1,108.00 " "$1,772.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310618 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT WRIST JOINT EACH 25443 "$2,168.00 " 960 "$1,517.60 " "$1,084.00 " "$1,734.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310626 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT WRIST JOINT EACH 25444 "$2,254.00 " 960 "$1,577.80 " "$1,127.00 " "$1,803.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310634 PHYSICIAN FEE - SURGERY PF-RECONSTRUCT WRIST JOINT EACH 25445 "$1,978.00 " 960 "$1,384.60 " $989.00 "$1,582.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316110 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION ANKLE JOINT EACH 27703 "$3,035.00 " 960 "$2,124.50 " "$1,517.50 " "$2,428.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336811 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION BILE DUCTS EACH 47800 "$4,359.00 " 960 "$3,051.30 " "$2,179.50 " "$3,487.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313554 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION HIP SOCKET EACH 27120 "$3,576.00 " 960 "$2,503.20 " "$1,788.00 " "$2,860.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313562 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION HIP SOCKET EACH 27122 "$3,039.00 " 960 "$2,127.30 " "$1,519.50 " "$2,431.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314826 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION KNEE EACH 27427 "$1,948.00 " 960 "$1,363.60 " $974.00 "$1,558.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314834 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION KNEE EACH 27428 "$3,075.00 " 960 "$2,152.50 " "$1,537.50 " "$2,460.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314842 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION KNEE EACH 27429 "$3,466.00 " 960 "$2,426.20 " "$1,733.00 " "$2,772.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335920 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF ANUS EACH 46753 "$1,741.00 " 960 "$1,218.70 " $870.50 "$1,392.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305097 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF CHIN EACH 21120 "$1,353.00 " 960 $947.10 $676.50 "$1,082.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305105 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF CHIN EACH 21121 "$1,383.00 " 960 $968.10 $691.50 "$1,106.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305113 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF CHIN EACH 21122 "$2,005.00 " 960 "$1,403.50 " "$1,002.50 " "$1,604.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305121 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF CHIN EACH 21123 "$2,199.00 " 960 "$1,539.30 " "$1,099.50 " "$1,759.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353055 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF EYELID EACH 67973 "$2,369.00 " 960 "$1,658.30 " "$1,184.50 " "$1,895.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353063 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF EYELID EACH 67974 "$2,359.00 " 960 "$1,651.30 " "$1,179.50 " "$1,887.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305568 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF JAW EACH 21245 "$2,462.00 " 960 "$1,723.40 " "$1,231.00 " "$1,969.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305576 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF JAW EACH 21246 "$2,216.00 " 960 "$1,551.20 " "$1,108.00 " "$1,772.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305592 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF JAW EACH 21248 "$2,074.00 " 960 "$1,451.80 " "$1,037.00 " "$1,659.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305600 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF JAW EACH 21249 "$2,901.00 " 960 "$2,030.70 " "$1,450.50 " "$2,320.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305527 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF JAW JOINT EACH 21240 "$2,733.00 " 960 "$1,913.10 " "$1,366.50 " "$2,186.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305535 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF JAW JOINT EACH 21242 "$2,638.00 " 960 "$1,846.60 " "$1,319.00 " "$2,110.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305543 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF JAW JOINT EACH 21243 "$4,364.00 " 960 "$3,054.80 " "$2,182.00 " "$3,491.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305550 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF LOWER JAW EACH 21244 "$2,661.00 " 960 "$1,862.70 " "$1,330.50 " "$2,128.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305386 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF MIDFACE EACH 21188 "$4,103.00 " 960 "$2,872.10 " "$2,051.50 " "$3,282.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330343 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF MOUTH EACH 40840 "$1,700.00 " 960 "$1,190.00 " $850.00 "$1,360.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330350 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF MOUTH EACH 40842 "$1,836.00 " 960 "$1,285.20 " $918.00 "$1,468.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330368 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF MOUTH EACH 40843 "$2,367.00 " 960 "$1,656.90 " "$1,183.50 " "$1,893.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330376 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF MOUTH EACH 40844 "$3,196.00 " 960 "$2,237.20 " "$1,598.00 " "$2,556.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330384 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF MOUTH EACH 40845 "$3,232.00 " 960 "$2,262.40 " "$1,616.00 " "$2,585.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320039 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF NOSE EACH 30400 "$3,252.00 " 960 "$2,276.40 " "$1,626.00 " "$2,601.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320047 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF NOSE EACH 30410 "$3,761.00 " 960 "$2,632.70 " "$1,880.50 " "$3,008.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320054 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF NOSE EACH 30420 "$3,851.00 " 960 "$2,695.70 " "$1,925.50 " "$3,080.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305626 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF ORBIT EACH 21256 "$3,362.00 " 960 "$2,353.40 " "$1,681.00 " "$2,689.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333271 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF PYLORUS EACH 43800 "$2,638.00 " 960 "$1,846.60 " "$1,319.00 " "$2,110.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306533 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF STERNUM EACH 21740 "$2,893.00 " 960 "$2,025.10 " "$1,446.50 " "$2,314.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331663 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF THROAT EACH 42950 "$2,096.00 " 960 "$1,467.20 " "$1,048.00 " "$1,676.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340920 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 53410 "$2,600.00 " 960 "$1,820.00 " "$1,300.00 " "$2,080.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340938 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 53415 "$2,994.00 " 960 "$2,095.80 " "$1,497.00 " "$2,395.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340961 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 53430 "$2,610.00 " 960 "$1,827.00 " "$1,305.00 " "$2,088.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341613 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 54308 "$1,903.00 " 960 "$1,332.10 " $951.50 "$1,522.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341621 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 54312 "$2,172.00 " 960 "$1,520.40 " "$1,086.00 " "$1,737.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341639 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 54316 "$2,637.00 " 960 "$1,845.90 " "$1,318.50 " "$2,109.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341647 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 54318 "$1,893.00 " 960 "$1,325.10 " $946.50 "$1,514.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341654 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 54322 "$2,074.00 " 960 "$1,451.80 " "$1,037.00 " "$1,659.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341662 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 54324 "$2,569.00 " 960 "$1,798.30 " "$1,284.50 " "$2,055.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341670 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF URETHRA EACH 54326 "$2,502.00 " 960 "$1,751.40 " "$1,251.00 " "$2,001.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321714 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION OF WINDPIPE EACH 31766 "$4,987.00 " 960 "$3,490.90 " "$2,493.50 " "$3,989.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330749 PHYSICIAN FEE - SURGERY PF-RECONSTRUCTION TONGUE FOLD EACH 41520 $667.00 960 $466.90 $333.50 $533.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360449 PHYSICIAN FEE - SURGERY PF-RECTUM SURGERY PROC NOS EACH 45999 $589.00 960 $412.30 $294.50 $471.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324353 PHYSICIAN FEE - SURGERY PF-REDO COMPL CARDIAC ANOMALY EACH 33622 "$9,641.00 " 960 "$6,748.70 " "$4,820.50 " "$7,712.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328792 PHYSICIAN FEE - SURGERY PF-REDO ENDOV VENA CAVA FILTR EACH 37192 $975.00 960 $682.50 $487.50 $780.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333578 PHYSICIAN FEE - SURGERY PF-REDUCE BOWEL OBSTRUCTION EACH 44050 "$2,646.00 " 960 "$1,852.20 " "$1,323.00 " "$2,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352875 PHYSICIAN FEE - SURGERY PF-REDUCE OVERCORRECTED PTOSIS EACH 67909 "$1,120.00 " 960 $784.00 $560.00 $896.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342033 PHYSICIAN FEE - SURGERY PF-REDUCE TESTIS TORSION EACH 54600 "$1,208.00 " 960 $845.60 $604.00 $966.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305477 PHYSICIAN FEE - SURGERY PF-REDUCTION OF FACIAL BONES EACH 21209 "$1,583.00 " 960 "$1,108.10 " $791.50 "$1,266.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305154 PHYSICIAN FEE - SURGERY PF-REDUCTION OF FOREHEAD EACH 21137 "$2,034.00 " 960 "$1,423.80 " "$1,017.00 " "$1,627.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305162 PHYSICIAN FEE - SURGERY PF-REDUCTION OF FOREHEAD EACH 21138 "$2,479.00 " 960 "$1,735.30 " "$1,239.50 " "$1,983.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305170 PHYSICIAN FEE - SURGERY PF-REDUCTION OF FOREHEAD EACH 21139 "$2,945.00 " 960 "$2,061.50 " "$1,472.50 " "$2,356.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303704 PHYSICIAN FEE - SURGERY PF-REDUCTION OF LARGE BREAST EACH 19318 "$2,483.00 " 960 "$1,738.10 " "$1,241.50 " "$1,986.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347396 PHYSICIAN FEE - SURGERY PF-REDUCTION OF SKULL DEFECT EACH 62115 "$5,067.00 " 960 "$3,546.90 " "$2,533.50 " "$4,053.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347404 PHYSICIAN FEE - SURGERY PF-REDUCTION OF SKULL DEFECT EACH 62117 "$5,935.00 " 960 "$4,154.50 " "$2,967.50 " "$4,748.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335334 PHYSICIAN FEE - SURGERY PF-REDUCTION RECTAL PROLAPSE EACH 45900 $596.00 960 $417.20 $298.00 $476.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321904 PHYSICIAN FEE - SURGERY PF-RE-EXPLORATION OF CHEST EACH 32120 "$2,438.00 " 960 "$1,706.60 " "$1,219.00 " "$1,950.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345630 PHYSICIAN FEE - SURGERY PF-RE-EXPLORE PARATHYROIDS EACH 60502 "$3,650.00 " 960 "$2,555.00 " "$1,825.00 " "$2,920.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327240 PHYSICIAN FEE - SURGERY PF-REIMPLANT ARTERY EACH EACH 35697 $414.00 960 $289.80 $207.00 $331.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339146 PHYSICIAN FEE - SURGERY PF-REIMPLANT URETER IN BLADDER EACH 50780 "$2,992.00 " 960 "$2,094.40 " "$1,496.00 " "$2,393.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339153 PHYSICIAN FEE - SURGERY PF-REIMPLANT URETER IN BLADDER EACH 50782 "$2,847.00 " 960 "$1,992.90 " "$1,423.50 " "$2,277.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339161 PHYSICIAN FEE - SURGERY PF-REIMPLANT URETER IN BLADDER EACH 50783 "$2,986.00 " 960 "$2,090.20 " "$1,493.00 " "$2,388.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339179 PHYSICIAN FEE - SURGERY PF-REIMPLANT URETER IN BLADDER EACH 50785 "$3,226.00 " 960 "$2,258.20 " "$1,613.00 " "$2,580.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338486 PHYSICIAN FEE - SURGERY PF-REIMPLANTATION OF KIDNEY EACH 50380 "$5,745.00 " 960 "$4,021.50 " "$2,872.50 " "$4,596.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308190 PHYSICIAN FEE - SURGERY PF-REINFORCE CLAVICLE EACH 23490 "$2,374.00 " 960 "$1,661.80 " "$1,187.00 " "$1,899.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352305 PHYSICIAN FEE - SURGERY PF-REINFORCE EYE WALL EACH 67250 "$2,308.00 " 960 "$1,615.60 " "$1,154.00 " "$1,846.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313794 PHYSICIAN FEE - SURGERY PF-REINFORCE HIP BONES EACH 27187 "$2,741.00 " 960 "$1,918.70 " "$1,370.50 " "$2,192.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309271 PHYSICIAN FEE - SURGERY PF-REINFORCE HUMERUS EACH 24498 "$2,390.00 " 960 "$1,673.00 " "$1,195.00 " "$1,912.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324486 PHYSICIAN FEE - SURGERY PF-REINFORCE PULMONARY ARTERY EACH 33690 "$3,370.00 " 960 "$2,359.00 " "$1,685.00 " "$2,696.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310691 PHYSICIAN FEE - SURGERY PF-REINFORCE RADIUS EACH 25490 "$1,986.00 " 960 "$1,390.20 " $993.00 "$1,588.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310717 PHYSICIAN FEE - SURGERY PF-REINFORCE RADIUS AND ULNA EACH 25492 "$2,501.00 " 960 "$1,750.70 " "$1,250.50 " "$2,000.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308208 PHYSICIAN FEE - SURGERY PF-REINFORCE SHOULDER BONES EACH 23491 "$2,798.00 " 960 "$1,958.60 " "$1,399.00 " "$2,238.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315138 PHYSICIAN FEE - SURGERY PF-REINFORCE THIGH EACH 27495 "$3,111.00 " 960 "$2,177.70 " "$1,555.50 " "$2,488.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316292 PHYSICIAN FEE - SURGERY PF-REINFORCE TIBIA EACH 27745 "$2,045.00 " 960 "$1,431.50 " "$1,022.50 " "$1,636.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310709 PHYSICIAN FEE - SURGERY PF-REINFORCE ULNA EACH 25491 "$2,043.00 " 960 "$1,430.10 " "$1,021.50 " "$1,634.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352313 PHYSICIAN FEE - SURGERY PF-REINFORCE/GRAFT EYE WALL EACH 67255 "$1,761.00 " 960 "$1,232.70 " $880.50 "$1,408.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321235 PHYSICIAN FEE - SURGERY PF-REINNERVATE LARYNX EACH 31590 "$2,422.00 " 960 "$1,695.40 " "$1,211.00 " "$1,937.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350929 PHYSICIAN FEE - SURGERY PF-REINSERT OCULAR IMPLANT EACH 65155 "$2,468.00 " 960 "$1,727.60 " "$1,234.00 " "$1,974.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307374 PHYSICIAN FEE - SURGERY PF-REINSERT SPINAL FIXATION EACH 22849 "$3,757.00 " 960 "$2,629.90 " "$1,878.50 " "$3,005.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308596 PHYSICIAN FEE - SURGERY PF-RELEASE ELBOW JOINT EACH 24006 "$1,963.00 " 960 "$1,374.10 " $981.50 "$1,570.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317472 PHYSICIAN FEE - SURGERY PF-RELEASE EXTENS TENDON-MULTI EACH 28226 "$1,097.00 " 960 $767.90 $548.50 $877.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352438 PHYSICIAN FEE - SURGERY PF-RELEASE EYE TISSUE EACH 67343 "$1,725.00 " 960 "$1,207.50 " $862.50 "$1,380.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354210 PHYSICIAN FEE - SURGERY PF-RELEASE FACIAL NERVE EACH 69720 "$3,128.00 " 960 "$2,189.60 " "$1,564.00 " "$2,502.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354228 PHYSICIAN FEE - SURGERY PF-RELEASE FACIAL NERVE EACH 69725 "$4,996.00 " 960 "$3,497.20 " "$2,498.00 " "$3,996.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354350 PHYSICIAN FEE - SURGERY PF-RELEASE FACIAL NERVE EACH 69955 "$5,257.00 " 960 "$3,679.90 " "$2,628.50 " "$4,205.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312283 PHYSICIAN FEE - SURGERY PF-RELEASE FINGER CONTRACTURE EACH 26525 "$1,826.00 " 960 "$1,278.20 " $913.00 "$1,460.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317456 PHYSICIAN FEE - SURGERY PF-RELEASE FLEXOR TENDON-MULTI EACH 28222 $985.00 960 $689.50 $492.50 $788.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350077 PHYSICIAN FEE - SURGERY PF-RELEASE FOOT/TOE NERVE EACH 64726 $708.00 960 $495.60 $354.00 $566.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311996 PHYSICIAN FEE - SURGERY PF-RELEASE FOREARM/HAND TENDON EACH 26449 "$1,913.00 " 960 "$1,339.10 " $956.50 "$1,530.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311988 PHYSICIAN FEE - SURGERY PF-RELEASE HAND/FINGER TENDON EACH 26445 "$1,601.00 " 960 "$1,120.70 " $800.50 "$1,280.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354368 PHYSICIAN FEE - SURGERY PF-RELEASE INNER EAR CANAL EACH 69960 "$5,049.00 " 960 "$3,534.30 " "$2,524.50 " "$4,039.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312275 PHYSICIAN FEE - SURGERY PF-RELEASE KNUCKLE CONTRACTURE EACH 26520 "$1,814.00 " 960 "$1,269.80 " $907.00 "$1,451.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315997 PHYSICIAN FEE - SURGERY PF-RELEASE LOWER LEG TENDONS EACH 27681 "$1,379.00 " 960 $965.30 $689.50 "$1,103.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354079 PHYSICIAN FEE - SURGERY PF-RELEASE MIDDLE EAR BONE EACH 69650 "$2,137.00 " 960 "$1,495.90 " "$1,068.50 " "$1,709.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317548 PHYSICIAN FEE - SURGERY PF-RELEASE MIDFOOT JOINT ONLY EACH 28260 "$1,456.00 " 960 "$1,019.20 " $728.00 "$1,164.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317571 PHYSICIAN FEE - SURGERY PF-RELEASE MIDTARSAL (HEYMAN) EACH 28264 "$1,800.00 " 960 "$1,260.00 " $900.00 "$1,440.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312556 PHYSICIAN FEE - SURGERY PF-RELEASE MUSCLES OF HAND EACH 26593 "$1,722.00 " 960 "$1,205.40 " $861.00 "$1,377.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317522 PHYSICIAN FEE - SURGERY PF-RELEASE OF BIG TOE EACH 28240 $776.00 960 $543.20 $388.00 $620.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351976 PHYSICIAN FEE - SURGERY PF-RELEASE OF EYE FLUID EACH 67015 "$1,543.00 " 960 "$1,080.10 " $771.50 "$1,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317589 PHYSICIAN FEE - SURGERY PF-RELEASE OF FOOT CONTRACTURE EACH 28270 $882.00 960 $617.40 $441.00 $705.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317449 PHYSICIAN FEE - SURGERY PF-RELEASE OF FOOT TENDON EACH 28220 $806.00 960 $564.20 $403.00 $644.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315989 PHYSICIAN FEE - SURGERY PF-RELEASE OF LOWER LEG TENDON EACH 27680 "$1,136.00 " 960 $795.20 $568.00 $908.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321995 PHYSICIAN FEE - SURGERY PF-RELEASE OF LUNG EACH 32220 "$4,464.00 " 960 "$3,124.80 " "$2,232.00 " "$3,571.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320153 PHYSICIAN FEE - SURGERY PF-RELEASE OF NASAL ADHESIONS EACH 30560 $399.00 960 $279.30 $199.50 $319.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346455 PHYSICIAN FEE - SURGERY PF-RELEASE OF SKULL SEAMS EACH 61550 "$3,584.00 " 960 "$2,508.80 " "$1,792.00 " "$2,867.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346463 PHYSICIAN FEE - SURGERY PF-RELEASE OF SKULL SEAMS EACH 61552 "$4,471.00 " 960 "$3,129.70 " "$2,235.50 " "$3,576.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348600 PHYSICIAN FEE - SURGERY PF-RELEASE OF SPINAL CORD EACH 63200 "$4,589.00 " 960 "$3,212.30 " "$2,294.50 " "$3,671.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317597 PHYSICIAN FEE - SURGERY PF-RELEASE OF TOE JOINT EACH EACH 28272 $659.00 960 $461.30 $329.50 $527.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339054 PHYSICIAN FEE - SURGERY PF-RELEASE OF URETER EACH 50715 "$3,305.00 " 960 "$2,313.50 " "$1,652.50 " "$2,644.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339062 PHYSICIAN FEE - SURGERY PF-RELEASE OF URETER EACH 50722 "$2,789.00 " 960 "$1,952.30 " "$1,394.50 " "$2,231.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339302 PHYSICIAN FEE - SURGERY PF-RELEASE OF URETER EACH 50940 "$2,354.00 " 960 "$1,647.80 " "$1,177.00 " "$1,883.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311970 PHYSICIAN FEE - SURGERY PF-RELEASE PALM & FINGER TEND EACH 26442 "$2,655.00 " 960 "$1,858.50 " "$1,327.50 " "$2,124.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311343 PHYSICIAN FEE - SURGERY PF-RELEASE PALM CONTRACTURE EACH 26040 $865.00 960 $605.50 $432.50 $692.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311350 PHYSICIAN FEE - SURGERY PF-RELEASE PALM CONTRACTURE EACH 26045 "$1,300.00 " 960 $910.00 $650.00 "$1,040.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311509 PHYSICIAN FEE - SURGERY PF-RELEASE PALM CONTRACTURE EACH 26121 "$1,646.00 " 960 "$1,152.20 " $823.00 "$1,316.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311517 PHYSICIAN FEE - SURGERY PF-RELEASE PALM CONTRACTURE EACH 26123 "$2,292.00 " 960 "$1,604.40 " "$1,146.00 " "$1,833.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311525 PHYSICIAN FEE - SURGERY PF-RELEASE PALM CONTRACTURE EACH 26125 $735.00 960 $514.50 $367.50 $588.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311962 PHYSICIAN FEE - SURGERY PF-RELEASE PALM/FINGER TENDON EACH 26440 "$1,729.00 " 960 "$1,210.30 " $864.50 "$1,383.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307556 PHYSICIAN FEE - SURGERY PF-RELEASE SHOULDER JOINT EACH 23020 "$1,900.00 " 960 "$1,330.00 " $950.00 "$1,520.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308034 PHYSICIAN FEE - SURGERY PF-RELEASE SHOULDER LIGAMENT EACH 23415 "$1,921.00 " 960 "$1,344.70 " $960.50 "$1,536.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312226 PHYSICIAN FEE - SURGERY PF-RELEASE THUMB CONTRACTURE EACH 26508 "$1,813.00 " 960 "$1,269.10 " $906.50 "$1,450.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310287 PHYSICIAN FEE - SURGERY PF-RELEASE WRIST/FOREARM TEND EACH 25295 "$1,447.00 " 960 "$1,012.90 " $723.50 "$1,157.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339070 PHYSICIAN FEE - SURGERY PF-RELEASE/REVISE URETER EACH 50725 "$2,919.00 " 960 "$2,043.30 " "$1,459.50 " "$2,335.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340656 PHYSICIAN FEE - SURGERY PF-RELIEVE BLADDER CONTRACTURE EACH 52640 $857.00 960 $599.90 $428.50 $685.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346109 PHYSICIAN FEE - SURGERY PF-RELIEVE CRANIAL PRESSURE EACH 61345 "$6,165.00 " 960 "$4,315.50 " "$3,082.50 " "$4,932.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351356 PHYSICIAN FEE - SURGERY PF-RELIEVE INNER EYE PRESSURE EACH 65820 "$2,101.00 " 960 "$1,470.70 " "$1,050.50 " "$1,680.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350069 PHYSICIAN FEE - SURGERY PF-RELIEVE PRESSURE NERVE(S) EACH 64722 "$1,027.00 " 960 $718.90 $513.50 $821.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342090 PHYSICIAN FEE - SURGERY PF-RELOCATION OF TESTIS(ES) EACH 54680 "$2,091.00 " 960 "$1,463.70 " "$1,045.50 " "$1,672.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336076 PHYSICIAN FEE - SURGERY PF-REM BY LIGAT INT HEM GRPS EACH 46946 "$1,014.00 " 960 $709.80 $507.00 $811.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350960 PHYSICIAN FEE - SURGERY PF-REM FB CORNEAL W/O SLIT LMP EACH 65220 $110.00 960 $77.00 $55.00 $88.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350978 PHYSICIAN FEE - SURGERY PF-REM FB CORNEAL W/SLIT LAMP EACH 65222 $128.00 960 $89.60 $64.00 $102.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317381 PHYSICIAN FEE - SURGERY PF-REM FOREIGN BODY FOOT DEEP EACH 28192 $816.00 960 $571.20 $408.00 $652.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335540 PHYSICIAN FEE - SURGERY PF-REM IN/EX HEM GRP W/FISTU EACH 46258 "$1,352.00 " 960 $946.40 $676.00 "$1,081.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335565 PHYSICIAN FEE - SURGERY PF-REM IN/EX HEM GRPS & FISS EACH 46261 "$1,457.00 " 960 "$1,019.90 " $728.50 "$1,165.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335573 PHYSICIAN FEE - SURGERY PF-REM IN/EX HEM GRPS W/FIST EACH 46262 "$1,640.00 " 960 "$1,148.00 " $820.00 "$1,312.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325343 PHYSICIAN FEE - SURGERY PF-REM INTRACORPOREAL DEVICE EACH 33980 "$4,989.00 " 960 "$3,492.30 " "$2,494.50 " "$3,991.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341860 PHYSICIAN FEE - SURGERY PF-REM SELF-CONTD PENIS PROS EACH 54415 "$1,419.00 " 960 $993.30 $709.50 "$1,135.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349012 PHYSICIAN FEE - SURGERY PF-REM SPINE ELTRD PERQ ARAY EACH 63661 $910.00 960 $637.00 $455.00 $728.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307382 PHYSICIAN FEE - SURGERY PF-REM SPINE FIXATION DEVICE EACH 22850 "$2,104.00 " 960 "$1,472.80 " "$1,052.00 " "$1,683.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307408 PHYSICIAN FEE - SURGERY PF-REM SPINE FIXATION DEVICE EACH 22852 "$2,027.00 " 960 "$1,418.90 " "$1,013.50 " "$1,621.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307416 PHYSICIAN FEE - SURGERY PF-REM SPINE FIXATION DEVICE EACH 22855 "$3,199.00 " 960 "$2,239.30 " "$1,599.50 " "$2,559.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345242 PHYSICIAN FEE - SURGERY PF-REM UTERUS AFTER CESAREAN EACH 59525 "$1,412.00 " 960 $988.40 $706.00 "$1,129.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325400 PHYSICIAN FEE - SURGERY PF-REM VAD DIFFERENT SESSION EACH 33992 $522.00 960 $365.40 $261.00 $417.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319015 PHYSICIAN FEE - SURGERY PF-REM/BIV GAUNT BOOT/BODY CST EACH 29700 $91.00 960 $63.70 $45.50 $72.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341878 PHYSICIAN FEE - SURGERY PF-REM/REPL PENIS CONTAIN PROS EACH 54416 "$1,910.00 " 960 "$1,337.00 " $955.00 "$1,528.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323389 PHYSICIAN FEE - SURGERY PF-REM/REPLC CVD GEN DUAL LEAD EACH 33263 "$1,062.00 " 960 $743.40 $531.00 $849.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323397 PHYSICIAN FEE - SURGERY PF-REM/REPLC CVD GEN MULT LEAD EACH 33264 "$1,108.00 " 960 $775.60 $554.00 $886.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323371 PHYSICIAN FEE - SURGERY PF-REM/REPLC CVD GEN SING LEAD EACH 33262 "$1,021.00 " 960 $714.70 $510.50 $816.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323140 PHYSICIAN FEE - SURGERY PF-REM/REPLC PM GEN MULT LEADS EACH 33229 "$1,022.00 " 960 $715.40 $511.00 $817.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341043 PHYSICIAN FEE - SURGERY PF-REM/REPLC UR SPHINCTR COMP EACH 53448 "$3,377.00 " 960 "$2,363.90 " "$1,688.50 " "$2,701.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350945 PHYSICIAN FEE - SURGERY PF-REMOV FOREIGN BDY FROM EYE EACH 65205 $73.00 960 $51.10 $36.50 $58.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350952 PHYSICIAN FEE - SURGERY PF-REMOV FOREIGN BDY FROM EYE EACH 65210 $91.00 960 $63.70 $45.50 $72.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350986 PHYSICIAN FEE - SURGERY PF-REMOV FOREIGN BDY FROM EYE EACH 65235 "$1,874.00 " 960 "$1,311.80 " $937.00 "$1,499.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350994 PHYSICIAN FEE - SURGERY PF-REMOV FOREIGN BDY FROM EYE EACH 65260 "$2,507.00 " 960 "$1,754.90 " "$1,253.50 " "$2,005.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351000 PHYSICIAN FEE - SURGERY PF-REMOV FOREIGN BDY FROM EYE EACH 65265 "$2,824.00 " 960 "$1,976.80 " "$1,412.00 " "$2,259.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341852 PHYSICIAN FEE - SURGERY PF-REMOV/REPLC PENIS PROS COMP EACH 54411 "$2,729.00 " 960 "$1,910.30 " "$1,364.50 " "$2,183.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329733 PHYSICIAN FEE - SURGERY PF-REMOVAL ABDOMEN LYMPH NODES EACH 38564 "$1,950.00 " 960 "$1,365.00 " $975.00 "$1,560.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337124 PHYSICIAN FEE - SURGERY PF-REMOVAL ALLOGRAFT PANCREAS EACH 48556 "$2,819.00 " 960 "$1,973.30 " "$1,409.50 " "$2,255.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317100 PHYSICIAN FEE - SURGERY PF-REMOVAL ANKLE/HEEL LESION EACH 28100 "$1,121.00 " 960 $784.70 $560.50 $896.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329949 PHYSICIAN FEE - SURGERY PF-REMOVAL CHEST LESION EACH 39200 "$2,444.00 " 960 "$1,710.80 " "$1,222.00 " "$1,955.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329956 PHYSICIAN FEE - SURGERY PF-REMOVAL CHEST LESION EACH 39220 "$3,162.00 " 960 "$2,213.40 " "$1,581.00 " "$2,529.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301161 PHYSICIAN FEE - SURGERY PF-REMOVAL CONTRACEPTIVE CAP EACH 11976 $255.00 960 $178.50 $127.50 $204.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317084 PHYSICIAN FEE - SURGERY PF-REMOVAL FOOT CYST/GANGLION EACH 28090 $817.00 960 $571.90 $408.50 $653.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317027 PHYSICIAN FEE - SURGERY PF-REMOVAL FOOT FASCIA-RADICAL EACH 28062 "$1,065.00 " 960 $745.50 $532.50 $852.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317134 PHYSICIAN FEE - SURGERY PF-REMOVAL FOOT LESION TAR/MET EACH 28104 $944.00 960 $660.80 $472.00 $755.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330780 PHYSICIAN FEE - SURGERY PF-REMOVAL FOREIGN BDY JAWBONE EACH 41806 $715.00 960 $500.50 $357.50 $572.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330772 PHYSICIAN FEE - SURGERY PF-REMOVAL FOREIGN BODY GUM EACH 41805 $501.00 960 $350.70 $250.50 $400.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330228 PHYSICIAN FEE - SURGERY PF-REMOVAL FOREIGN BODY MOUTH EACH 40805 $515.00 960 $360.50 $257.50 $412.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317399 PHYSICIAN FEE - SURGERY "PF-REMOVAL FT FOREIGN BODY, SC" EACH 28193 $960.00 960 $672.00 $480.00 $768.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317209 PHYSICIAN FEE - SURGERY PF-REMOVAL FTH METATARSAL HEAD EACH 28113 "$1,123.00 " 960 $786.10 $561.50 $898.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311715 PHYSICIAN FEE - SURGERY PF-REMOVAL IMPLANT FROM HAND EACH 26320 $956.00 960 $669.20 $478.00 $764.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304298 PHYSICIAN FEE - SURGERY PF-REMOVAL IMPLANT-SUPERFICIAL EACH 20670 $387.00 960 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319882 PHYSICIAN FEE - SURGERY PF-REMOVAL INTRANASAL LESION EACH 30117 "$1,088.00 " 960 $761.60 $544.00 $870.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319890 PHYSICIAN FEE - SURGERY PF-REMOVAL INTRANASAL LESION EACH 30118 "$1,879.00 " 960 "$1,315.30 " $939.50 "$1,503.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338304 PHYSICIAN FEE - SURGERY PF-REMOVAL KIDNEY OPEN COMPLEX EACH 50225 "$3,258.00 " 960 "$2,280.60 " "$1,629.00 " "$2,606.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338312 PHYSICIAN FEE - SURGERY PF-REMOVAL KIDNEY OPEN RADICAL EACH 50230 "$3,414.00 " 960 "$2,389.80 " "$1,707.00 " "$2,731.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329709 PHYSICIAN FEE - SURGERY PF-REMOVAL NECK/ARMPIT LESION EACH 38550 "$1,465.00 " 960 "$1,025.50 " $732.50 "$1,172.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329717 PHYSICIAN FEE - SURGERY PF-REMOVAL NECK/ARMPIT LESION EACH 38555 "$2,895.00 " 960 "$2,026.50 " "$1,447.50 " "$2,316.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331549 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ADENOIDS EACH 42831 $620.00 960 $434.00 $310.00 $496.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331556 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ADENOIDS EACH 42835 $533.00 960 $373.10 $266.50 $426.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331564 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ADENOIDS EACH 42836 $660.00 960 $462.00 $330.00 $528.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331531 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ADENOIDS EACH 42830 $572.00 960 $400.40 $286.00 $457.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335474 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ANAL FISSURE EACH 46200 $905.00 960 $633.50 $452.50 $724.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335508 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ANAL TAGS EACH 46230 $474.00 960 $331.80 $237.00 $379.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317290 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ANKLE BONE EACH 28130 "$1,652.00 " 960 "$1,156.40 " $826.00 "$1,321.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316128 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ANKLE IMPLANT EACH 27704 "$1,543.00 " 960 "$1,080.10 " $771.50 "$1,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334642 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ANORECTAL LESION EACH 45108 "$1,052.00 " 960 $736.40 $526.00 $841.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325459 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ARM ARTERY CLOT EACH 34111 "$1,671.00 " 960 "$1,169.70 " $835.50 "$1,336.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308794 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ARM BONE LESION EACH 24134 "$2,064.00 " 960 "$1,444.80 " "$1,032.00 " "$1,651.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308919 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ARM FOREIGN BODY EACH 24200 $385.00 960 $269.50 $192.50 $308.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308927 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ARM FOREIGN BODY EACH 24201 "$1,101.00 " 960 $770.70 $550.50 $880.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325442 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ARTERY CLOT EACH 34101 "$1,672.00 " 960 "$1,170.40 " $836.00 "$1,337.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325426 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ARTERY CLOT EACH 34001 "$2,586.00 " 960 "$1,810.20 " "$1,293.00 " "$2,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325434 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ARTERY CLOT EACH 34051 "$2,751.00 " 960 "$1,925.70 " "$1,375.50 " "$2,200.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325467 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ARTERY CLOT EACH 34151 "$3,913.00 " 960 "$2,739.10 " "$1,956.50 " "$3,130.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325475 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ARTERY CLOT EACH 34201 "$2,875.00 " 960 "$2,012.50 " "$1,437.50 " "$2,300.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339633 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BLADDER EACH 51570 "$3,909.00 " 960 "$2,736.30 " "$1,954.50 " "$3,127.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339641 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BLADDER & NODES EACH 51575 "$4,802.00 " 960 "$3,361.40 " "$2,401.00 " "$3,841.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339666 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BLADDER & NODES EACH 51585 "$5,575.00 " 960 "$3,902.50 " "$2,787.50 " "$4,460.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339559 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BLADDER CYST EACH 51500 "$1,694.00 " 960 "$1,185.80 " $847.00 "$1,355.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339567 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BLADDER LESION EACH 51520 "$1,584.00 " 960 "$1,108.80 " $792.00 "$1,267.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339575 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BLADDER LESION EACH 51525 "$2,278.00 " 960 "$1,594.60 " "$1,139.00 " "$1,822.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339583 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BLADDER LESION EACH 51530 "$2,045.00 " 960 "$1,431.50 " "$1,022.50 " "$1,636.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339484 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BLADDER STONE EACH 51050 "$1,257.00 " 960 $879.90 $628.50 "$1,005.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304454 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BONE FOR GRAFT EACH 20900 $489.00 960 $342.30 $244.50 $391.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304462 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BONE FOR GRAFT EACH 20902 $752.00 960 $526.40 $376.00 $601.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307770 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BONE LESION EACH 23140 "$1,535.00 " 960 "$1,074.50 " $767.50 "$1,228.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307788 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BONE LESION EACH 23145 "$1,921.00 " 960 "$1,344.70 " $960.50 "$1,536.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307796 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BONE LESION EACH 23146 "$1,723.00 " 960 "$1,206.10 " $861.50 "$1,378.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346190 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN ABSCESS EACH 61514 "$5,764.00 " 960 "$4,034.80 " "$2,882.00 " "$4,611.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346265 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN ABSCESS EACH 61522 "$6,607.00 " 960 "$4,624.90 " "$3,303.50 " "$5,285.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346208 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61516 "$5,650.00 " 960 "$3,955.00 " "$2,825.00 " "$4,520.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346224 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61518 "$8,352.00 " 960 "$5,846.40 " "$4,176.00 " "$6,681.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346240 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61520 "$11,034.00 " 960 "$7,723.80 " "$5,517.00 " "$8,827.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346257 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61521 "$9,612.00 " 960 "$6,728.40 " "$4,806.00 " "$7,689.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346273 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61524 "$6,292.00 " 960 "$4,404.40 " "$3,146.00 " "$5,033.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346281 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61526 "$9,615.00 " 960 "$6,730.50 " "$4,807.50 " "$7,692.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346299 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61530 "$9,292.00 " 960 "$6,504.40 " "$4,646.00 " "$7,433.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346323 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61534 "$4,974.00 " 960 "$3,481.80 " "$2,487.00 " "$3,979.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346349 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61536 "$7,789.00 " 960 "$5,452.30 " "$3,894.50 " "$6,231.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346356 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN TISSUE EACH 61537 "$7,437.00 " 960 "$5,205.90 " "$3,718.50 " "$5,949.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346364 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN TISSUE EACH 61538 "$8,051.00 " 960 "$5,635.70 " "$4,025.50 " "$6,440.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346372 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN TISSUE EACH 61539 "$7,129.00 " 960 "$4,990.30 " "$3,564.50 " "$5,703.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346380 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN TISSUE EACH 61540 "$6,575.00 " 960 "$4,602.50 " "$3,287.50 " "$5,260.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346539 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BRAIN TISSUE EACH 61566 "$6,768.00 " 960 "$4,737.60 " "$3,384.00 " "$5,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303878 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BREAST CAPSULE EACH 19371 "$1,934.00 " 960 "$1,353.80 " $967.00 "$1,547.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303738 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BREAST IMPLANT EACH 19328 "$1,506.00 " 960 "$1,054.20 " $753.00 "$1,204.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303613 PHYSICIAN FEE - SURGERY PF-REMOVAL OF BREAST TISSUE EACH 19300 "$1,189.00 " 960 $832.30 $594.50 $951.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307549 PHYSICIAN FEE - SURGERY PF-REMOVAL OF CALCIUM DEPOSITS EACH 23000 $977.00 960 $683.90 $488.50 $781.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343718 PHYSICIAN FEE - SURGERY PF-REMOVAL OF CERVIX EACH 57530 "$1,016.00 " 960 $711.20 $508.00 $812.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343726 PHYSICIAN FEE - SURGERY PF-REMOVAL OF CERVIX RADICAL EACH 57531 "$5,336.00 " 960 "$3,735.20 " "$2,668.00 " "$4,268.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322019 PHYSICIAN FEE - SURGERY PF-REMOVAL OF CHEST LINING EACH 32310 "$2,573.00 " 960 "$1,801.10 " "$1,286.50 " "$2,058.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327356 PHYSICIAN FEE - SURGERY PF-REMOVAL OF CLOT IN GRAFT EACH 35875 "$1,657.00 " 960 "$1,159.90 " $828.50 "$1,325.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327364 PHYSICIAN FEE - SURGERY PF-REMOVAL OF CLOT IN GRAFT EACH 35876 "$2,646.00 " 960 "$1,852.20 " "$1,323.00 " "$2,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307754 PHYSICIAN FEE - SURGERY PF-REMOVAL OF COLLAR BONE EACH 23125 "$1,635.00 " 960 "$1,144.50 " $817.50 "$1,308.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333776 PHYSICIAN FEE - SURGERY PF-REMOVAL OF COLON EACH 44150 "$5,138.00 " 960 "$3,596.60 " "$2,569.00 " "$4,110.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333834 PHYSICIAN FEE - SURGERY PF-REMOVAL OF COLON EACH 44160 "$3,481.00 " 960 "$2,436.70 " "$1,740.50 " "$2,784.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333784 PHYSICIAN FEE - SURGERY PF-REMOVAL OF COLON/ILEOSTOMY EACH 44151 "$6,072.00 " 960 "$4,250.40 " "$3,036.00 " "$4,857.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333792 PHYSICIAN FEE - SURGERY PF-REMOVAL OF COLON/ILEOSTOMY EACH 44155 "$5,700.00 " 960 "$3,990.00 " "$2,850.00 " "$4,560.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333800 PHYSICIAN FEE - SURGERY PF-REMOVAL OF COLON/ILEOSTOMY EACH 44156 "$6,492.00 " 960 "$4,544.40 " "$3,246.00 " "$5,193.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317167 PHYSICIAN FEE - SURGERY "PF-REMOVAL OF CYST/TUMOR, FOOT" EACH 28108 $760.00 960 $532.00 $380.00 $608.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308711 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ELBOW BURSA EACH 24105 $988.00 960 $691.60 $494.00 $790.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308885 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ELBOW JOINT EACH 24155 "$2,351.00 " 960 "$1,645.70 " "$1,175.50 " "$1,880.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342165 PHYSICIAN FEE - SURGERY PF-REMOVAL OF EPIDIDYMIS EACH 54860 "$1,117.00 " 960 $781.90 $558.50 $893.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342173 PHYSICIAN FEE - SURGERY PF-REMOVAL OF EPIDIDYMIS EACH 54861 "$1,515.00 " 960 "$1,060.50 " $757.50 "$1,212.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320864 PHYSICIAN FEE - SURGERY PF-REMOVAL OF EPIGLOTTIS EACH 31420 "$2,223.00 " 960 "$1,556.10 " "$1,111.50 " "$1,778.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331804 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ESOPHAGUS EACH 43107 "$8,364.00 " 960 "$5,854.80 " "$4,182.00 " "$6,691.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331812 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ESOPHAGUS EACH 43108 "$12,511.00 " 960 "$8,757.70 " "$6,255.50 " "$10,008.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331820 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ESOPHAGUS EACH 43112 "$9,694.00 " 960 "$6,785.80 " "$4,847.00 " "$7,755.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331838 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ESOPHAGUS EACH 43113 "$12,224.00 " 960 "$8,556.80 " "$6,112.00 " "$9,779.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331903 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ESOPHAGUS EACH 43124 "$10,706.00 " 960 "$7,494.20 " "$5,353.00 " "$8,564.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331911 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ESOPHAGUS POUCH EACH 43130 "$2,171.00 " 960 "$1,519.70 " "$1,085.50 " "$1,736.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331929 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ESOPHAGUS POUCH EACH 43135 "$4,136.00 " 960 "$2,895.20 " "$2,068.00 " "$3,308.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320468 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ETHMOID SINUS EACH 31200 "$1,613.00 " 960 "$1,129.10 " $806.50 "$1,290.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320476 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ETHMOID SINUS EACH 31201 "$2,063.00 " 960 "$1,444.10 " "$1,031.50 " "$1,650.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320484 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ETHMOID SINUS EACH 31205 "$2,438.00 " 960 "$1,706.60 " "$1,219.00 " "$1,950.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320591 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ETHMOID SINUS EACH 31255 $867.00 960 $606.90 $433.50 $693.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353584 PHYSICIAN FEE - SURGERY PF-REMOVAL OF EXTERNAL EAR EACH 69120 "$1,023.00 " 960 $716.10 $511.50 $818.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350812 PHYSICIAN FEE - SURGERY PF-REMOVAL OF EYE EACH 65101 "$2,175.00 " 960 "$1,522.50 " "$1,087.50 " "$1,740.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350846 PHYSICIAN FEE - SURGERY PF-REMOVAL OF EYE EACH 65110 "$3,377.00 " 960 "$2,363.90 " "$1,688.50 " "$2,701.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360415 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FACE WRINKLES EACH 15828 $300.00 960 $210.00 $150.00 $240.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344567 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FALLOPIAN TUBE EACH 58700 "$2,205.00 " 960 "$1,543.50 " "$1,102.50 " "$1,764.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304496 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FASCIA FOR GRAFT EACH 20920 "$1,074.00 " 960 $751.80 $537.00 $859.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304504 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FASCIA FOR GRAFT EACH 20922 "$1,385.00 " 960 $969.50 $692.50 "$1,108.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311632 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FINGER LESION EACH 26210 "$1,230.00 " 960 $861.00 $615.00 $984.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311590 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FINGER TENDON EACH 26180 "$1,235.00 " 960 $864.50 $617.50 $988.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304280 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FIXATION DEVICE EACH 20665 $254.00 960 $177.80 $127.00 $203.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310006 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FOREARM LESION EACH 25120 "$1,380.00 " 960 $966.00 $690.00 "$1,104.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304082 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FOREIGN BODY EACH 20525 $673.00 960 $471.10 $336.50 $538.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304074 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FOREIGN BODY EACH 20520 $396.00 960 $277.20 $198.00 $316.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314560 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FOREIGN BODY EACH 27372 "$1,105.00 " 960 $773.50 $552.50 $884.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320393 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FRONTAL SINUS EACH 31080 "$2,890.00 " 960 "$2,023.00 " "$1,445.00 " "$2,312.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320401 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FRONTAL SINUS EACH 31081 "$3,102.00 " 960 "$2,171.40 " "$1,551.00 " "$2,481.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320419 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FRONTAL SINUS EACH 31084 "$3,213.00 " 960 "$2,249.10 " "$1,606.50 " "$2,570.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320427 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FRONTAL SINUS EACH 31085 "$3,312.00 " 960 "$2,318.40 " "$1,656.00 " "$2,649.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320435 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FRONTAL SINUS EACH 31086 "$3,126.00 " 960 "$2,188.20 " "$1,563.00 " "$2,500.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320443 PHYSICIAN FEE - SURGERY PF-REMOVAL OF FRONTAL SINUS EACH 31087 "$2,987.00 " 960 "$2,090.90 " "$1,493.50 " "$2,389.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336621 PHYSICIAN FEE - SURGERY PF-REMOVAL OF GALLBLADDER EACH 47600 "$3,026.00 " 960 "$2,118.20 " "$1,513.00 " "$2,420.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336639 PHYSICIAN FEE - SURGERY PF-REMOVAL OF GALLBLADDER EACH 47605 "$3,191.00 " 960 "$2,233.70 " "$1,595.50 " "$2,552.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336647 PHYSICIAN FEE - SURGERY PF-REMOVAL OF GALLBLADDER EACH 47610 "$3,539.00 " 960 "$2,477.30 " "$1,769.50 " "$2,831.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336654 PHYSICIAN FEE - SURGERY PF-REMOVAL OF GALLBLADDER EACH 47612 "$3,616.00 " 960 "$2,531.20 " "$1,808.00 " "$2,892.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336662 PHYSICIAN FEE - SURGERY PF-REMOVAL OF GALLBLADDER EACH 47620 "$3,908.00 " 960 "$2,735.60 " "$1,954.00 " "$3,126.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330855 PHYSICIAN FEE - SURGERY PF-REMOVAL OF GUM TISSUE EACH 41830 $839.00 960 $587.30 $419.50 $671.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307903 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HEAD OF HUMERUS EACH 23195 "$2,057.00 " 960 "$1,439.90 " "$1,028.50 " "$1,645.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308786 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HEAD OF RADIUS EACH 24130 "$1,403.00 " 960 $982.10 $701.50 "$1,122.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322878 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HEART LESION EACH 33120 "$5,848.00 " 960 "$4,093.60 " "$2,924.00 " "$4,678.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322886 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HEART LESION EACH 33130 "$3,789.00 " 960 "$2,652.30 " "$1,894.50 " "$3,031.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324197 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HEART LESION EACH 33542 "$7,331.00 " 960 "$5,131.70 " "$3,665.50 " "$5,864.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322860 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HEART SAC LESION EACH 33050 "$2,821.00 " 960 "$1,974.70 " "$1,410.50 " "$2,256.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317233 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HEEL BONE EACH 28118 "$1,133.00 " 960 $793.10 $566.50 $906.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317241 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HEEL SPUR EACH 28119 $965.00 960 $675.50 $482.50 $772.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335631 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HEMORRHOID CLOT EACH 46320 $309.00 960 $216.30 $154.50 $247.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313273 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HIP JOINT LINING EACH 27054 "$1,897.00 " 960 "$1,327.90 " $948.50 "$1,517.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313448 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HIP PROSTHESIS EACH 27090 "$2,283.00 " 960 "$1,598.10 " "$1,141.50 " "$1,826.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313455 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HIP PROSTHESIS EACH 27091 "$4,383.00 " 960 "$3,068.10 " "$2,191.50 " "$3,506.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307804 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HUMERUS LESION EACH 23150 "$1,842.00 " 960 "$1,289.40 " $921.00 "$1,473.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307812 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HUMERUS LESION EACH 23155 "$2,200.00 " 960 "$1,540.00 " "$1,100.00 " "$1,760.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307820 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HUMERUS LESION EACH 23156 "$1,874.00 " 960 "$1,311.80 " $937.00 "$1,499.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342223 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HYDROCELE EACH 55040 $905.00 960 $633.50 $452.50 $724.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342363 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HYDROCELE EACH 55500 "$1,056.00 " 960 $739.20 $528.00 $844.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342231 PHYSICIAN FEE - SURGERY PF-REMOVAL OF HYDROCELES EACH 55041 "$1,366.00 " 960 $956.20 $683.00 "$1,092.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303746 PHYSICIAN FEE - SURGERY PF-REMOVAL OF IMPLANT MATERIAL EACH 19330 "$1,758.00 " 960 "$1,230.60 " $879.00 "$1,406.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327828 PHYSICIAN FEE - SURGERY PF-REMOVAL OF INFUSION PUMP EACH 36262 $881.00 960 $616.70 $440.50 $704.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352032 PHYSICIAN FEE - SURGERY PF-REMOVAL OF INNER EYE FLUID EACH 67036 "$2,290.00 " 960 "$1,603.00 " "$1,145.00 " "$1,832.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351786 PHYSICIAN FEE - SURGERY PF-REMOVAL OF INNER EYE LESION EACH 66770 "$1,230.00 " 960 $861.00 $615.00 $984.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351653 PHYSICIAN FEE - SURGERY PF-REMOVAL OF IRIS EACH 66605 "$2,783.00 " 960 "$1,948.10 " "$1,391.50 " "$2,226.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351661 PHYSICIAN FEE - SURGERY PF-REMOVAL OF IRIS EACH 66625 "$1,096.00 " 960 $767.20 $548.00 $876.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351679 PHYSICIAN FEE - SURGERY PF-REMOVAL OF IRIS EACH 66630 "$1,450.00 " 960 "$1,015.00 " $725.00 "$1,160.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351687 PHYSICIAN FEE - SURGERY PF-REMOVAL OF IRIS EACH 66635 "$1,463.00 " 960 "$1,024.10 " $731.50 "$1,170.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313307 PHYSICIAN FEE - SURGERY PF-REMOVAL OF ISCHIAL BURSA EACH 27060 "$1,290.00 " 960 $903.00 $645.00 "$1,032.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304850 PHYSICIAN FEE - SURGERY PF-REMOVAL OF JAW BONE LESION EACH 21044 "$2,304.00 " 960 "$1,612.80 " "$1,152.00 " "$1,843.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304918 PHYSICIAN FEE - SURGERY PF-REMOVAL OF JAW JOINT EACH 21050 "$2,250.00 " 960 "$1,575.00 " "$1,125.00 " "$1,800.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338445 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KIDNEY EACH 50340 "$2,706.00 " 960 "$1,894.20 " "$1,353.00 " "$2,164.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338320 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KIDNEY & URETER EACH 50234 "$3,456.00 " 960 "$2,419.20 " "$1,728.00 " "$2,764.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338338 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KIDNEY & URETER EACH 50236 "$3,873.00 " 960 "$2,711.10 " "$1,936.50 " "$3,098.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338361 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KIDNEY LESION EACH 50280 "$2,508.00 " 960 "$1,755.60 " "$1,254.00 " "$2,006.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338379 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KIDNEY LESION EACH 50290 "$2,387.00 " 960 "$1,670.90 " "$1,193.50 " "$1,909.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338163 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KIDNEY STONE EACH 50060 "$3,019.00 " 960 "$2,113.30 " "$1,509.50 " "$2,415.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338197 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KIDNEY STONE EACH 50075 "$3,857.00 " 960 "$2,699.90 " "$1,928.50 " "$3,085.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338254 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KIDNEY STONE EACH 50130 "$2,736.00 " 960 "$1,915.20 " "$1,368.00 " "$2,188.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314388 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KNEE CARTILAGE EACH 27332 "$1,781.00 " 960 "$1,246.70 " $890.50 "$1,424.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314396 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KNEE CARTILAGE EACH 27333 "$1,628.00 " 960 "$1,139.60 " $814.00 "$1,302.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314453 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KNEE CYST EACH 27345 "$1,340.00 " 960 $938.00 $670.00 "$1,072.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315120 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KNEE PROSTHESIS EACH 27488 "$3,304.00 " 960 "$2,312.80 " "$1,652.00 " "$2,643.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314479 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KNEECAP EACH 27350 "$1,802.00 " 960 "$1,261.40 " $901.00 "$1,441.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314446 PHYSICIAN FEE - SURGERY PF-REMOVAL OF KNEECAP BURSA EACH 27340 "$1,034.00 " 960 $723.80 $517.00 $827.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320757 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LARYNX EACH 31360 "$5,486.00 " 960 "$3,840.20 " "$2,743.00 " "$4,388.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320765 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LARYNX EACH 31365 "$6,777.00 " 960 "$4,743.90 " "$3,388.50 " "$5,421.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320831 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LARYNX & PHARYNX EACH 31390 "$7,470.00 " 960 "$5,229.00 " "$3,735.00 " "$5,976.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320922 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LARYNX LESION EACH 31512 $347.00 960 $242.90 $173.50 $277.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321169 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LARYNX LESION EACH 31578 $401.00 960 $280.70 $200.50 $320.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320732 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LARYNX LESION EACH 31300 "$3,318.00 " 960 "$2,322.60 " "$1,659.00 " "$2,654.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354921 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LEFT HEART VENT EACH 33989 "$1,369.00 " 960 $958.30 $684.50 "$1,095.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325483 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LEG ARTERY CLOT EACH 34203 "$2,666.00 " 960 "$1,866.20 " "$1,333.00 " "$2,132.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329329 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LEG VEINS/LESION EACH 37735 "$1,645.00 " 960 "$1,151.50 " $822.50 "$1,316.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351828 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LENS LESION EACH 66830 "$1,814.00 " 960 "$1,269.80 " $907.00 "$1,451.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351836 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LENS MATERIAL EACH 66840 "$1,771.00 " 960 "$1,239.70 " $885.50 "$1,416.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351851 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LENS MATERIAL EACH 66852 "$2,143.00 " 960 "$1,500.10 " "$1,071.50 " "$1,714.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322050 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LUNG EACH 32440 "$4,396.00 " 960 "$3,077.20 " "$2,198.00 " "$3,516.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322076 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LUNG EACH 32445 "$9,916.00 " 960 "$6,941.20 " "$4,958.00 " "$7,932.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322209 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LUNG LESION EACH 32540 "$4,851.00 " 960 "$3,395.70 " "$2,425.50 " "$3,880.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321920 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LUNG LESION(S) EACH 32140 "$2,776.00 " 960 "$1,943.20 " "$1,388.00 " "$2,220.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321946 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LUNG LESION(S) EACH 32150 "$2,840.00 " 960 "$1,988.00 " "$1,420.00 " "$2,272.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329774 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LYMPH NODES NECK EACH 38700 "$2,172.00 " 960 "$1,520.40 " "$1,086.00 " "$1,737.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329782 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LYMPH NODES NECK EACH 38720 "$3,665.00 " 960 "$2,565.50 " "$1,832.50 " "$2,932.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329790 PHYSICIAN FEE - SURGERY PF-REMOVAL OF LYMPH NODES NECK EACH 38724 "$3,924.00 " 960 "$2,746.80 " "$1,962.00 " "$3,139.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317308 PHYSICIAN FEE - SURGERY PF-REMOVAL OF METATARSAL EACH 28140 "$1,142.00 " 960 $799.40 $571.00 $913.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317217 PHYSICIAN FEE - SURGERY PF-REMOVAL OF METATARSAL HEADS EACH 28114 "$2,237.00 " 960 "$1,565.90 " "$1,118.50 " "$1,789.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300924 PHYSICIAN FEE - SURGERY PF-REMOVAL OF NAIL PLATE EACH 11730 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350325 PHYSICIAN FEE - SURGERY PF-REMOVAL OF NERVE LESION EACH 64790 "$2,398.00 " 960 "$1,678.60 " "$1,199.00 " "$1,918.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350333 PHYSICIAN FEE - SURGERY PF-REMOVAL OF NERVE LESION EACH 64792 "$3,036.00 " 960 "$2,125.20 " "$1,518.00 " "$2,428.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319965 PHYSICIAN FEE - SURGERY PF-REMOVAL OF NOSE EACH 30160 "$2,170.00 " 960 "$1,519.00 " "$1,085.00 " "$1,736.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319924 PHYSICIAN FEE - SURGERY PF-REMOVAL OF NOSE LESION EACH 30125 "$1,738.00 " 960 "$1,216.60 " $869.00 "$1,390.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319866 PHYSICIAN FEE - SURGERY PF-REMOVAL OF NOSE POLYP(S) EACH 30110 $355.00 960 $248.50 $177.50 $284.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319874 PHYSICIAN FEE - SURGERY PF-REMOVAL OF NOSE POLYP(S) EACH 30115 "$1,228.00 " 960 $859.60 $614.00 $982.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350937 PHYSICIAN FEE - SURGERY PF-REMOVAL OF OCULAR IMPLANT EACH 65175 "$1,991.00 " 960 "$1,393.70 " $995.50 "$1,592.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337306 PHYSICIAN FEE - SURGERY PF-REMOVAL OF OMENTUM EACH 49255 "$2,206.00 " 960 "$1,544.20 " "$1,103.00 " "$1,764.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344708 PHYSICIAN FEE - SURGERY PF-REMOVAL OF OVARIAN CYST(S) EACH 58925 "$2,113.00 " 960 "$1,479.10 " "$1,056.50 " "$1,690.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344716 PHYSICIAN FEE - SURGERY PF-REMOVAL OF OVARY(S) EACH 58940 "$1,524.00 " 960 "$1,066.80 " $762.00 "$1,219.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344724 PHYSICIAN FEE - SURGERY PF-REMOVAL OF OVARY(S) EACH 58943 "$3,279.00 " 960 "$2,295.30 " "$1,639.50 " "$2,623.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344575 PHYSICIAN FEE - SURGERY PF-REMOVAL OF OVARY/TUBE(S) EACH 58720 "$2,082.00 " 960 "$1,457.40 " "$1,041.00 " "$1,665.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323173 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PACEMAKER SYSTEM EACH 33233 $635.00 960 $444.50 $317.50 $508.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323181 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PACEMAKER SYSTEM EACH 33234 "$1,327.00 " 960 $928.90 $663.50 "$1,061.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311582 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PALM TENDON EACH EACH 26170 "$1,121.00 " 960 $784.70 $560.50 $896.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337009 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PANCREAS EACH 48155 "$5,125.00 " 960 "$3,587.50 " "$2,562.50 " "$4,100.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336910 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PANCREAS LESION EACH 48120 "$3,162.00 " 960 "$2,213.40 " "$1,581.00 " "$2,529.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336951 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PANCREATIC DUCT EACH 48148 "$3,547.00 " 960 "$2,482.90 " "$1,773.50 " "$2,837.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336878 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PANCREATIC STONE EACH 48020 "$3,346.00 " 960 "$2,342.20 " "$1,673.00 " "$2,676.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343932 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PELVIS CONTENTS EACH 58240 "$7,978.00 " 960 "$5,584.60 " "$3,989.00 " "$6,382.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341423 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PENIS EACH 54125 "$2,192.00 " 960 "$1,534.40 " "$1,096.00 " "$1,753.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301013 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PILONIDAL LESION EACH 11770 $515.00 960 $360.50 $257.50 $412.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301021 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PILONIDAL LESION EACH 11771 "$1,247.00 " 960 $872.90 $623.50 $997.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301039 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PILONIDAL LESION EACH 11772 "$1,592.00 " 960 "$1,114.40 " $796.00 "$1,273.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346430 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PITUITARY GLAND EACH 61546 "$6,973.00 " 960 "$4,881.10 " "$3,486.50 " "$5,578.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346448 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PITUITARY GLAND EACH 61548 "$4,628.00 " 960 "$3,239.60 " "$2,314.00 " "$3,702.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342512 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PROSTATE EACH 55801 "$2,903.00 " 960 "$2,032.10 " "$1,451.50 " "$2,322.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342553 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PROSTATE EACH 55821 "$2,227.00 " 960 "$1,558.90 " "$1,113.50 " "$1,781.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342561 PHYSICIAN FEE - SURGERY PF-REMOVAL OF PROSTATE EACH 55831 "$2,284.00 " 960 "$1,598.80 " "$1,142.00 " "$1,827.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335391 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RECTAL MARKER EACH 46030 $235.00 960 $164.50 $117.50 $188.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334659 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RECTUM EACH 45110 "$4,939.00 " 960 "$3,457.30 " "$2,469.50 " "$3,951.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334675 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RECTUM EACH 45112 "$4,831.00 " 960 "$3,381.70 " "$2,415.50 " "$3,864.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334725 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RECTUM EACH 45120 "$4,539.00 " 960 "$3,177.30 " "$2,269.50 " "$3,631.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334733 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RECTUM AND COLON EACH 45121 "$4,961.00 " 960 "$3,472.70 " "$2,480.50 " "$3,968.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343734 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RESIDUAL CERVIX EACH 57540 "$2,164.00 " 960 "$1,514.80 " "$1,082.00 " "$1,731.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343759 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RESIDUAL CERVIX EACH 57550 "$1,178.00 " 960 $824.60 $589.00 $942.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306426 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RIB EACH 21615 "$1,760.00 " 960 "$1,232.00 " $880.00 "$1,408.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306434 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RIB AND NERVES EACH 21616 "$2,027.00 " 960 "$1,418.90 " "$1,013.50 " "$1,621.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322720 PHYSICIAN FEE - SURGERY PF-REMOVAL OF RIB(S) EACH 32900 "$3,822.00 " 960 "$2,675.40 " "$1,911.00 " "$3,057.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331150 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SALIVARY STONE EACH 42330 $443.00 960 $310.10 $221.50 $354.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331176 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SALIVARY STONE EACH 42340 $927.00 960 $648.90 $463.50 $741.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342280 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SCROTUM EACH 55150 "$1,318.00 " 960 $922.60 $659.00 "$1,054.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342272 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SCROTUM LESION EACH 55120 $948.00 960 $663.60 $474.00 $758.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317845 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SESAMOID BONE EACH 28315 $862.00 960 $603.40 $431.00 $689.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337553 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SHUNT EACH 49429 "$1,297.00 " 960 $907.90 $648.50 "$1,037.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346158 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SKULL LESION EACH 61500 "$3,752.00 " 960 "$2,626.40 " "$1,876.00 " "$3,001.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333628 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SMALL INTESTINE EACH 44120 "$3,450.00 " 960 "$2,415.00 " "$1,725.00 " "$2,760.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333636 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SMALL INTESTINE EACH 44121 $681.00 960 $476.70 $340.50 $544.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333644 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SMALL INTESTINE EACH 44125 "$3,296.00 " 960 "$2,307.20 " "$1,648.00 " "$2,636.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342322 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPERM DUCT(S) EACH 55250 $609.00 960 $426.30 $304.50 $487.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348055 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63001 "$3,635.00 " 960 "$2,544.50 " "$1,817.50 " "$2,908.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348063 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63003 "$3,645.00 " 960 "$2,551.50 " "$1,822.50 " "$2,916.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348071 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63005 "$3,537.00 " 960 "$2,475.90 " "$1,768.50 " "$2,829.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348089 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63011 "$3,088.00 " 960 "$2,161.60 " "$1,544.00 " "$2,470.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348097 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63012 "$3,485.00 " 960 "$2,439.50 " "$1,742.50 " "$2,788.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348105 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63015 "$4,395.00 " 960 "$3,076.50 " "$2,197.50 " "$3,516.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348113 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63016 "$4,512.00 " 960 "$3,158.40 " "$2,256.00 " "$3,609.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348121 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63017 "$3,747.00 " 960 "$2,622.90 " "$1,873.50 " "$2,997.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348204 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63045 "$3,783.00 " 960 "$2,648.10 " "$1,891.50 " "$3,026.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348212 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63046 "$3,582.00 " 960 "$2,507.40 " "$1,791.00 " "$2,865.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348220 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL LAMINA EACH 63047 "$3,196.00 " 960 "$2,237.20 " "$1,598.00 " "$2,556.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349178 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPINAL SHUNT EACH 63746 "$1,814.00 " 960 "$1,269.80 " $907.00 "$1,451.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329428 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPLEEN PARTIAL EACH 38101 "$3,306.00 " 960 "$2,314.20 " "$1,653.00 " "$2,644.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329436 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPLEEN TOTAL EACH 38102 $737.00 960 $515.90 $368.50 $589.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329410 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SPLEEN TOTAL EACH 38100 "$3,243.00 " 960 "$2,270.10 " "$1,621.50 " "$2,594.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332968 PHYSICIAN FEE - SURGERY PF-REMOVAL OF STOMACH EACH 43620 "$5,640.00 " 960 "$3,948.00 " "$2,820.00 " "$4,512.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332976 PHYSICIAN FEE - SURGERY PF-REMOVAL OF STOMACH EACH 43621 "$6,450.00 " 960 "$4,515.00 " "$3,225.00 " "$5,160.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332984 PHYSICIAN FEE - SURGERY PF-REMOVAL OF STOMACH EACH 43622 "$6,575.00 " 960 "$4,602.50 " "$3,287.50 " "$5,260.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333032 PHYSICIAN FEE - SURGERY PF-REMOVAL OF STOMACH PARTIAL EACH 43635 $320.00 960 $224.00 $160.00 $256.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332992 PHYSICIAN FEE - SURGERY PF-REMOVAL OF STOMACH PARTIAL EACH 43631 "$4,104.00 " 960 "$2,872.80 " "$2,052.00 " "$3,283.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333008 PHYSICIAN FEE - SURGERY PF-REMOVAL OF STOMACH PARTIAL EACH 43632 "$5,774.00 " 960 "$4,041.80 " "$2,887.00 " "$4,619.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333016 PHYSICIAN FEE - SURGERY PF-REMOVAL OF STOMACH PARTIAL EACH 43633 "$5,459.00 " 960 "$3,821.30 " "$2,729.50 " "$4,367.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333024 PHYSICIAN FEE - SURGERY PF-REMOVAL OF STOMACH PARTIAL EACH 43634 "$6,047.00 " 960 "$4,232.90 " "$3,023.50 " "$4,837.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304306 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SUPPORT IMPLANT EACH 20680 "$1,143.00 " 960 $800.10 $571.50 $914.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335938 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SUTURE FROM ANUS EACH 46754 $643.00 960 $450.10 $321.50 $514.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302722 PHYSICIAN FEE - SURGERY PF-REMOVAL OF SUTURES EACH 15851 $151.00 960 $105.70 $75.50 $120.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313414 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TAIL BONE EACH 27080 "$1,424.00 " 960 $996.80 $712.00 "$1,139.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302755 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TAIL BONE ULCER EACH 15920 "$1,739.00 " 960 "$1,217.30 " $869.50 "$1,391.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302763 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TAIL BONE ULCER EACH 15922 "$2,154.00 " 960 "$1,507.80 " "$1,077.00 " "$1,723.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353295 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TEAR GLAND EACH 68500 "$2,717.00 " 960 "$1,901.90 " "$1,358.50 " "$2,173.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353329 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TEAR SAC EACH 68520 "$1,890.00 " 960 "$1,323.00 " $945.00 "$1,512.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304512 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TENDON FOR GRAFT EACH 20924 "$1,376.00 " 960 $963.20 $688.00 "$1,100.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315765 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TENDON LESION EACH 27630 $963.00 960 $674.10 $481.50 $770.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341977 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TESTIS EACH 54520 $880.00 960 $616.00 $440.00 $704.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341993 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TESTIS EACH 54530 "$1,359.00 " 960 $951.30 $679.50 "$1,087.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345663 PHYSICIAN FEE - SURGERY PF-REMOVAL OF THYMUS GLAND EACH 60520 "$2,954.00 " 960 "$2,067.80 " "$1,477.00 " "$2,363.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345671 PHYSICIAN FEE - SURGERY PF-REMOVAL OF THYMUS GLAND EACH 60521 "$3,150.00 " 960 "$2,205.00 " "$1,575.00 " "$2,520.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345689 PHYSICIAN FEE - SURGERY PF-REMOVAL OF THYMUS GLAND EACH 60522 "$3,826.00 " 960 "$2,678.20 " "$1,913.00 " "$3,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345531 PHYSICIAN FEE - SURGERY PF-REMOVAL OF THYROID EACH 60240 "$2,540.00 " 960 "$1,778.00 " "$1,270.00 " "$2,032.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345549 PHYSICIAN FEE - SURGERY PF-REMOVAL OF THYROID EACH 60252 "$3,646.00 " 960 "$2,552.20 " "$1,823.00 " "$2,916.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345572 PHYSICIAN FEE - SURGERY PF-REMOVAL OF THYROID EACH 60270 "$3,775.00 " 960 "$2,642.50 " "$1,887.50 " "$3,020.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345580 PHYSICIAN FEE - SURGERY PF-REMOVAL OF THYROID EACH 60271 "$2,912.00 " 960 "$2,038.40 " "$1,456.00 " "$2,329.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317092 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TOE LESIONS EACH 28092 $721.00 960 $504.70 $360.50 $576.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330632 PHYSICIAN FEE - SURGERY PF-REMOVAL OF TONGUE EACH 41140 "$5,758.00 " 960 "$4,030.60 " "$2,879.00 " "$4,606.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320492 PHYSICIAN FEE - SURGERY PF-REMOVAL OF UPPER JAW EACH 31225 "$4,810.00 " 960 "$3,367.00 " "$2,405.00 " "$3,848.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320500 PHYSICIAN FEE - SURGERY PF-REMOVAL OF UPPER JAW EACH 31230 "$5,377.00 " 960 "$3,763.90 " "$2,688.50 " "$4,301.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338981 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETER EACH 50650 "$2,766.00 " 960 "$1,936.20 " "$1,383.00 " "$2,212.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338999 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETER EACH 50660 "$3,029.00 " 960 "$2,120.30 " "$1,514.50 " "$2,423.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338957 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETER STONE EACH 50610 "$2,503.00 " 960 "$1,752.10 " "$1,251.50 " "$2,002.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338965 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETER STONE EACH 50620 "$2,067.00 " 960 "$1,446.90 " "$1,033.50 " "$1,653.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338973 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETER STONE EACH 50630 "$2,368.00 " 960 "$1,657.60 " "$1,184.00 " "$1,894.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339492 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETER STONE EACH 51060 "$1,551.00 " 960 "$1,085.70 " $775.50 "$1,240.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340797 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETHRA EACH 53210 "$2,066.00 " 960 "$1,446.20 " "$1,033.00 " "$1,652.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340805 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETHRA EACH 53215 "$2,457.00 " 960 "$1,719.90 " "$1,228.50 " "$1,965.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340854 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETHRA GLAND EACH 53250 "$1,055.00 " 960 $738.50 $527.50 $844.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340888 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETHRA GLAND EACH 53270 $492.00 960 $344.40 $246.00 $393.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340821 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETHRA LESION EACH 53230 "$1,636.00 " 960 "$1,145.20 " $818.00 "$1,308.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340839 PHYSICIAN FEE - SURGERY PF-REMOVAL OF URETHRA LESION EACH 53235 "$1,686.00 " 960 "$1,180.20 " $843.00 "$1,348.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325491 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VEIN CLOT EACH 34401 "$4,132.00 " 960 "$2,892.40 " "$2,066.00 " "$3,305.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325509 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VEIN CLOT EACH 34421 "$1,964.00 " 960 "$1,374.80 " $982.00 "$1,571.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325517 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VEIN CLOT EACH 34451 "$4,066.00 " 960 "$2,846.20 " "$2,033.00 " "$3,252.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325525 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VEIN CLOT EACH 34471 "$3,052.00 " 960 "$2,136.40 " "$1,526.00 " "$2,441.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325533 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VEIN CLOT EACH 34490 "$1,624.00 " 960 "$1,136.80 " $812.00 "$1,299.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348352 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63081 "$5,152.00 " 960 "$3,606.40 " "$2,576.00 " "$4,121.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348378 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63085 "$5,693.00 " 960 "$3,985.10 " "$2,846.50 " "$4,554.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348394 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63087 "$7,063.00 " 960 "$4,944.10 " "$3,531.50 " "$5,650.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348410 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63090 "$5,560.00 " 960 "$3,892.00 " "$2,780.00 " "$4,448.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348436 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63101 "$6,854.00 " 960 "$4,797.80 " "$3,427.00 " "$5,483.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348444 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63102 "$6,659.00 " 960 "$4,661.30 " "$3,329.50 " "$5,327.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348857 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63300 "$5,311.00 " 960 "$3,717.70 " "$2,655.50 " "$4,248.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348865 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63301 "$6,660.00 " 960 "$4,662.00 " "$3,330.00 " "$5,328.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348873 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63302 "$6,579.00 " 960 "$4,605.30 " "$3,289.50 " "$5,263.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348881 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63303 "$6,992.00 " 960 "$4,894.40 " "$3,496.00 " "$5,593.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348907 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63305 "$7,553.00 " 960 "$5,287.10 " "$3,776.50 " "$6,042.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348915 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63306 "$7,419.00 " 960 "$5,193.30 " "$3,709.50 " "$5,935.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348923 PHYSICIAN FEE - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63307 "$7,269.00 " 960 "$5,088.30 " "$3,634.50 " "$5,815.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310105 PHYSICIAN FEE - SURGERY PF-REMOVAL OF WRIST BONE EACH 25210 "$1,356.00 " 960 $949.20 $678.00 "$1,084.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310113 PHYSICIAN FEE - SURGERY PF-REMOVAL OF WRIST BONES EACH 25215 "$1,701.00 " 960 "$1,190.70 " $850.50 "$1,360.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310030 PHYSICIAN FEE - SURGERY PF-REMOVAL OF WRIST LESION EACH 25130 "$1,238.00 " 960 $866.60 $619.00 $990.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310162 PHYSICIAN FEE - SURGERY PF-REMOVAL OF WRIST PROSTHESIS EACH 25250 "$1,475.00 " 960 "$1,032.50 " $737.50 "$1,180.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310170 PHYSICIAN FEE - SURGERY PF-REMOVAL OF WRIST PROSTHESIS EACH 25251 "$1,989.00 " 960 "$1,392.30 " $994.50 "$1,591.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323199 PHYSICIAN FEE - SURGERY PF-REMOVAL PACEMAKER ELECTRODE EACH 33235 "$1,743.00 " 960 "$1,220.10 " $871.50 "$1,394.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329725 PHYSICIAN FEE - SURGERY PF-REMOVAL PELVIC LYMPH NODES EACH 38562 "$1,929.00 " 960 "$1,350.30 " $964.50 "$1,543.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339708 PHYSICIAN FEE - SURGERY PF-REMOVAL PELVIC STRUCTURES EACH 51597 "$6,108.00 " 960 "$4,275.60 " "$3,054.00 " "$4,886.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357692 PHYSICIAN FEE - SURGERY PF-REMOVAL PRESSURE SORE NOS EACH 15999 "$1,982.00 " 960 "$1,387.40 " $991.00 "$1,585.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342371 PHYSICIAN FEE - SURGERY PF-REMOVAL SPERM CORD LESION EACH 55520 "$1,286.00 " 960 $900.20 $643.00 "$1,028.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361215 PHYSICIAN FEE - SURGERY PF-REMOVAL SUTR&STAPL XREQ ANS EACH 15854 $42.00 960 $29.40 $21.00 $33.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361207 PHYSICIAN FEE - SURGERY PF-REMOVAL SUTR/STAPL XREQ ANS EACH 15853 $31.00 960 $21.70 $15.50 $24.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300692 PHYSICIAN FEE - SURGERY PF-REMOVAL SWEAT GLAND LESION EACH 11470 $786.00 960 $550.20 $393.00 $628.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300650 PHYSICIAN FEE - SURGERY PF-REMOVAL SWEAT GLAND LESION EACH 11450 $721.00 960 $504.70 $360.50 $576.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300668 PHYSICIAN FEE - SURGERY PF-REMOVAL SWEAT GLAND LESION EACH 11451 $911.00 960 $637.70 $455.50 $728.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300676 PHYSICIAN FEE - SURGERY PF-REMOVAL SWEAT GLAND LESION EACH 11462 $685.00 960 $479.50 $342.50 $548.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300684 PHYSICIAN FEE - SURGERY PF-REMOVAL SWEAT GLAND LESION EACH 11463 $912.00 960 $638.40 $456.00 $729.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300700 PHYSICIAN FEE - SURGERY PF-REMOVAL SWEAT GLAND LESION EACH 11471 $958.00 960 $670.60 $479.00 $766.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310048 PHYSICIAN FEE - SURGERY PF-REMOVE & GRAFT WRIST LESION EACH 25135 "$1,553.00 " 960 "$1,087.10 " $776.50 "$1,242.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310055 PHYSICIAN FEE - SURGERY PF-REMOVE & GRAFT WRIST LESION EACH 25136 "$1,375.00 " 960 $962.50 $687.50 "$1,100.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346414 PHYSICIAN FEE - SURGERY PF-REMOVE & TREAT BRAIN LESION EACH 61544 "$5,737.00 " 960 "$4,015.90 " "$2,868.50 " "$4,589.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329832 PHYSICIAN FEE - SURGERY PF-REMOVE ABD LYMPH NODES EACH 38747 $754.00 960 $527.80 $377.00 $603.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329873 PHYSICIAN FEE - SURGERY PF-REMOVE ABDOMEN LYMPH NODES EACH 38780 "$2,894.00 " 960 "$2,025.80 " "$1,447.00 " "$2,315.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335615 PHYSICIAN FEE - SURGERY PF-REMOVE ANAL FIST 2 STAGE EACH 46285 "$1,148.00 " 960 $803.60 $574.00 $918.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335607 PHYSICIAN FEE - SURGERY PF-REMOVE ANAL FIST COMPLEX EACH 46280 "$1,301.00 " 960 $910.70 $650.50 "$1,040.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335599 PHYSICIAN FEE - SURGERY PF-REMOVE ANAL FIST INTER EACH 46275 "$1,143.00 " 960 $800.10 $571.50 $914.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335581 PHYSICIAN FEE - SURGERY PF-REMOVE ANAL FIST SUBQ EACH 46270 "$1,091.00 " 960 $763.70 $545.50 $872.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346828 PHYSICIAN FEE - SURGERY PF-REMOVE ANEURYSM SINUS EACH 61613 "$9,809.00 " 960 "$6,866.30 " "$4,904.50 " "$7,847.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315740 PHYSICIAN FEE - SURGERY PF-REMOVE ANKLE JOINT LINING EACH 27625 "$1,547.00 " 960 "$1,082.90 " $773.50 "$1,237.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315757 PHYSICIAN FEE - SURGERY PF-REMOVE ANKLE JOINT LINING EACH 27626 "$1,681.00 " 960 "$1,176.70 " $840.50 "$1,344.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324924 PHYSICIAN FEE - SURGERY PF-REMOVE AORTA CONSTRICTION EACH 33840 "$3,477.00 " 960 "$2,433.90 " "$1,738.50 " "$2,781.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324932 PHYSICIAN FEE - SURGERY PF-REMOVE AORTA CONSTRICTION EACH 33845 "$3,746.00 " 960 "$2,622.20 " "$1,873.00 " "$2,996.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324940 PHYSICIAN FEE - SURGERY PF-REMOVE AORTA CONSTRICTION EACH 33851 "$3,573.00 " 960 "$2,501.10 " "$1,786.50 " "$2,858.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325244 PHYSICIAN FEE - SURGERY PF-REMOVE AORTIC ASSIST DEVICE EACH 33968 $94.00 960 $65.80 $47.00 $75.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329808 PHYSICIAN FEE - SURGERY PF-REMOVE ARMPIT LYMPH NODES EACH 38740 "$1,980.00 " 960 "$1,386.00 " $990.00 "$1,584.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329816 PHYSICIAN FEE - SURGERY PF-REMOVE ARMPIT LYMPH NODES EACH 38745 "$2,495.00 " 960 "$1,746.50 " "$1,247.50 " "$1,996.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340391 PHYSICIAN FEE - SURGERY PF-REMOVE BLADDER STONE EACH 52317 $912.00 960 $638.40 $456.00 $729.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340409 PHYSICIAN FEE - SURGERY PF-REMOVE BLADDER STONE EACH 52318 "$1,249.00 " 960 $874.30 $624.50 $999.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339690 PHYSICIAN FEE - SURGERY PF-REMOVE BLADDER/CREATE POUCH EACH 51596 "$6,237.00 " 960 "$4,365.90 " "$3,118.50 " "$4,989.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339658 PHYSICIAN FEE - SURGERY PF-REMOVE BLADDER/REVISE TRACT EACH 51580 "$5,014.00 " 960 "$3,509.80 " "$2,507.00 " "$4,011.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339674 PHYSICIAN FEE - SURGERY PF-REMOVE BLADDER/REVISE TRACT EACH 51590 "$5,114.00 " 960 "$3,579.80 " "$2,557.00 " "$4,091.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339682 PHYSICIAN FEE - SURGERY PF-REMOVE BLADDER/REVISE TRACT EACH 51595 "$5,787.00 " 960 "$4,050.90 " "$2,893.50 " "$4,629.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304348 PHYSICIAN FEE - SURGERY PF-REMOVE BONE FIXATION DEVICE EACH 20694 $931.00 960 $651.70 $465.50 $744.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345788 PHYSICIAN FEE - SURGERY PF-REMOVE BRAIN CANAL FLUID EACH 61050 $208.00 960 $145.60 $104.00 $166.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345762 PHYSICIAN FEE - SURGERY PF-REMOVE BRAIN CAVITY FLUID EACH 61020 $315.00 960 $220.50 $157.50 $252.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347685 PHYSICIAN FEE - SURGERY PF-REMOVE BRAIN CAVITY SHUNT EACH 62256 "$1,814.00 " 960 "$1,269.80 " $907.00 "$1,451.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346331 PHYSICIAN FEE - SURGERY PF-REMOVE BRAIN ELECTRODES EACH 61535 "$3,013.00 " 960 "$2,109.10 " "$1,506.50 " "$2,410.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346182 PHYSICIAN FEE - SURGERY PF-REMOVE BRAIN LINING LESION EACH 61512 "$7,701.00 " 960 "$5,390.70 " "$3,850.50 " "$6,160.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346232 PHYSICIAN FEE - SURGERY PF-REMOVE BRAIN LINING LESION EACH 61519 "$8,875.00 " 960 "$6,212.50 " "$4,437.50 " "$7,100.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347552 PHYSICIAN FEE - SURGERY PF-REMOVE BRAIN TUMOR W/SCOPE EACH 62164 "$6,310.00 " 960 "$4,417.00 " "$3,155.00 " "$5,048.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336068 PHYSICIAN FEE - SURGERY PF-REMOVE BY LIGAT INT HEM GRP EACH 46945 $907.00 960 $634.90 $453.50 $725.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345713 PHYSICIAN FEE - SURGERY PF-REMOVE CAROTID BODY LESION EACH 60600 "$3,847.00 " 960 "$2,692.90 " "$1,923.50 " "$3,077.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345721 PHYSICIAN FEE - SURGERY PF-REMOVE CAROTID BODY LESION EACH 60605 "$4,653.00 " 960 "$3,257.10 " "$2,326.50 " "$3,722.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304470 PHYSICIAN FEE - SURGERY PF-REMOVE CARTILAGE FOR GRAFT EACH 20910 "$1,306.00 " 960 $914.20 $653.00 "$1,044.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304488 PHYSICIAN FEE - SURGERY PF-REMOVE CARTILAGE FOR GRAFT EACH 20912 "$1,300.00 " 960 $910.00 $650.00 "$1,040.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307465 PHYSICIAN FEE - SURGERY PF-REMOVE CERV ARTIF DISC EACH 22864 "$6,234.00 " 960 "$4,363.80 " "$3,117.00 " "$4,987.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343775 PHYSICIAN FEE - SURGERY PF-REMOVE CERVIX REPAIR BOWEL EACH 57556 "$1,605.00 " 960 "$1,123.50 " $802.50 "$1,284.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343742 PHYSICIAN FEE - SURGERY PF-REMOVE CERVIX/REPAIR PELVIS EACH 57545 "$2,281.00 " 960 "$1,596.70 " "$1,140.50 " "$1,824.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343767 PHYSICIAN FEE - SURGERY PF-REMOVE CERVIX/REPAIR VAGINA EACH 57555 "$1,691.00 " 960 "$1,183.70 " $845.50 "$1,352.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307838 PHYSICIAN FEE - SURGERY PF-REMOVE COLLAR BONE LESION EACH 23170 "$1,561.00 " 960 "$1,092.70 " $780.50 "$1,248.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307861 PHYSICIAN FEE - SURGERY PF-REMOVE COLLAR BONE LESION EACH 23180 "$1,828.00 " 960 "$1,279.60 " $914.00 "$1,462.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347537 PHYSICIAN FEE - SURGERY PF-REMOVE COLLOID CYST W/SCOPE EACH 62162 "$5,701.00 " 960 "$3,990.70 " "$2,850.50 " "$4,560.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304934 PHYSICIAN FEE - SURGERY PF-REMOVE CORONOID PROCESS EACH 21070 "$1,637.00 " 960 "$1,145.90 " $818.50 "$1,309.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345747 PHYSICIAN FEE - SURGERY PF-REMOVE CRANIAL CAVITY FLUID EACH 61000 $341.00 960 $238.70 $170.50 $272.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345754 PHYSICIAN FEE - SURGERY PF-REMOVE CRANIAL CAVITY FLUID EACH 61001 $322.00 960 $225.40 $161.00 $257.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350242 PHYSICIAN FEE - SURGERY PF-REMOVE DIGIT NERVE LESION EACH 64776 "$1,101.00 " 960 $770.70 $550.50 $880.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301195 PHYSICIAN FEE - SURGERY PF-REMOVE DRUG IMPLANT DEVICE EACH 11982 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353592 PHYSICIAN FEE - SURGERY PF-REMOVE EAR CANAL LESION(S) EACH 69140 "$2,367.00 " 960 "$1,656.90 " "$1,183.50 " "$1,893.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353600 PHYSICIAN FEE - SURGERY PF-REMOVE EAR CANAL LESION(S) EACH 69145 $684.00 960 $478.80 $342.00 $547.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353840 PHYSICIAN FEE - SURGERY PF-REMOVE EAR LESION EACH 69540 $345.00 960 $241.50 $172.50 $276.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353857 PHYSICIAN FEE - SURGERY PF-REMOVE EAR LESION EACH 69550 "$2,799.00 " 960 "$1,959.30 " "$1,399.50 " "$2,239.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353865 PHYSICIAN FEE - SURGERY PF-REMOVE EAR LESION EACH 69552 "$4,203.00 " 960 "$2,942.10 " "$2,101.50 " "$3,362.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353873 PHYSICIAN FEE - SURGERY PF-REMOVE EAR LESION EACH 69554 "$6,746.00 " 960 "$4,722.20 " "$3,373.00 " "$5,396.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308810 PHYSICIAN FEE - SURGERY PF-REMOVE ELBOW BONE LESION EACH 24138 "$1,891.00 " 960 "$1,323.70 " $945.50 "$1,512.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308893 PHYSICIAN FEE - SURGERY PF-REMOVE ELBOW JOINT IMPLANT EACH 24160 "$3,461.00 " 960 "$2,422.70 " "$1,730.50 " "$2,768.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308703 PHYSICIAN FEE - SURGERY PF-REMOVE ELBOW JOINT LINING EACH 24102 "$1,698.00 " 960 "$1,188.60 " $849.00 "$1,358.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308752 PHYSICIAN FEE - SURGERY PF-REMOVE ELBOW LESION EACH 24120 "$1,467.00 " 960 "$1,026.90 " $733.50 "$1,173.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323207 PHYSICIAN FEE - SURGERY PF-REMOVE ELECTRODE/THORACOTMY EACH 33236 "$2,164.00 " 960 "$1,514.80 " "$1,082.00 " "$1,731.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323215 PHYSICIAN FEE - SURGERY PF-REMOVE ELECTRODE/THORACOTMY EACH 33237 "$2,327.00 " 960 "$1,628.90 " "$1,163.50 " "$1,861.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323223 PHYSICIAN FEE - SURGERY PF-REMOVE ELECTRODE/THORACOTMY EACH 33238 "$2,633.00 " 960 "$1,843.10 " "$1,316.50 " "$2,106.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323264 PHYSICIAN FEE - SURGERY PF-REMOVE ELTRD TRANSVEN EACH 33244 "$2,370.00 " 960 "$1,659.00 " "$1,185.00 " "$1,896.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323256 PHYSICIAN FEE - SURGERY PF-REMOVE ELTRD/THORACOTOMY EACH 33243 "$3,836.00 " 960 "$2,685.20 " "$1,918.00 " "$3,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342140 PHYSICIAN FEE - SURGERY PF-REMOVE EPIDIDYMIS LESION EACH 54830 $993.00 960 $695.10 $496.50 $794.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342157 PHYSICIAN FEE - SURGERY PF-REMOVE EPIDIDYMIS LESION EACH 54840 $858.00 960 $600.60 $429.00 $686.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304819 PHYSICIAN FEE - SURGERY PF-REMOVE EXOSTOSIS MANDIBLE EACH 21031 $711.00 960 $497.70 $355.50 $568.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304827 PHYSICIAN FEE - SURGERY PF-REMOVE EXOSTOSIS MAXILLA EACH 21032 $682.00 960 $477.40 $341.00 $545.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335516 PHYSICIAN FEE - SURGERY PF-REMOVE EXT HEM GROUPS 2+ EACH 46250 $868.00 960 $607.60 $434.00 $694.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353576 PHYSICIAN FEE - SURGERY PF-REMOVE EXTERNAL EAR PARTIAL EACH 69110 $868.00 960 $607.60 $434.00 $694.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306764 PHYSICIAN FEE - SURGERY PF-REMOVE EXTRA SPINE SEGMENT EACH 22116 $411.00 960 $287.70 $205.50 $328.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306723 PHYSICIAN FEE - SURGERY PF-REMOVE EXTRA SPINE SEGMENT EACH 22103 $380.00 960 $266.00 $190.00 $304.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352172 PHYSICIAN FEE - SURGERY PF-REMOVE EYE IMPLANT MATERIAL EACH 67120 "$1,418.00 " 960 $992.60 $709.00 "$1,134.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352180 PHYSICIAN FEE - SURGERY PF-REMOVE EYE IMPLANT MATERIAL EACH 67121 "$2,308.00 " 960 "$1,615.60 " "$1,154.00 " "$1,846.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351430 PHYSICIAN FEE - SURGERY PF-REMOVE EYE LESION EACH 65900 "$2,532.00 " 960 "$1,772.40 " "$1,266.00 " "$2,025.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351489 PHYSICIAN FEE - SURGERY PF-REMOVE EYE LESION EACH 66130 "$1,443.00 " 960 "$1,010.10 " $721.50 "$1,154.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350838 PHYSICIAN FEE - SURGERY PF-REMOVE EYE/ATTACH IMPLANT EACH 65105 "$2,443.00 " 960 "$1,710.10 " "$1,221.50 " "$1,954.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350820 PHYSICIAN FEE - SURGERY PF-REMOVE EYE/INSERT IMPLANT EACH 65103 "$2,247.00 " 960 "$1,572.90 " "$1,123.50 " "$1,797.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350853 PHYSICIAN FEE - SURGERY PF-REMOVE EYE/REVISE SOCKET EACH 65112 "$3,871.00 " 960 "$2,709.70 " "$1,935.50 " "$3,096.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350861 PHYSICIAN FEE - SURGERY PF-REMOVE EYE/REVISE SOCKET EACH 65114 "$4,039.00 " 960 "$2,827.30 " "$2,019.50 " "$3,231.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353006 PHYSICIAN FEE - SURGERY PF-REMOVE EYELID FOREIGN BODY EACH 67938 $300.00 960 $210.00 $150.00 $240.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352693 PHYSICIAN FEE - SURGERY PF-REMOVE EYELID LESION(S) EACH 67808 $943.00 960 $660.10 $471.50 $754.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353113 PHYSICIAN FEE - SURGERY PF-REMOVE EYELID LINING LESION EACH 68110 $380.00 960 $266.00 $190.00 $304.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353139 PHYSICIAN FEE - SURGERY PF-REMOVE EYELID LINING LESION EACH 68130 "$1,056.00 " 960 $739.20 $528.00 $844.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353147 PHYSICIAN FEE - SURGERY PF-REMOVE EYELID LINING LESION EACH 68135 $383.00 960 $268.10 $191.50 $306.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314511 PHYSICIAN FEE - SURGERY PF-REMOVE FEMUR LES/FIXATION EACH 27358 $757.00 960 $529.90 $378.50 $605.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314487 PHYSICIAN FEE - SURGERY PF-REMOVE FEMUR LESION EACH 27355 "$1,677.00 " 960 "$1,173.90 " $838.50 "$1,341.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313315 PHYSICIAN FEE - SURGERY PF-REMOVE FEMUR LESION/BURSA EACH 27062 "$1,251.00 " 960 $875.70 $625.50 "$1,000.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314495 PHYSICIAN FEE - SURGERY PF-REMOVE FEMUR LESION/GRAFT EACH 27356 "$2,043.00 " 960 "$1,430.10 " "$1,021.50 " "$1,634.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314503 PHYSICIAN FEE - SURGERY PF-REMOVE FEMUR LESION/GRAFT EACH 27357 "$2,254.00 " 960 "$1,577.80 " "$1,127.00 " "$1,803.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311608 PHYSICIAN FEE - SURGERY PF-REMOVE FINGER BONE EACH 26185 "$1,536.00 " 960 "$1,075.20 " $768.00 "$1,228.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310063 PHYSICIAN FEE - SURGERY PF-REMOVE FOREARM BONE LESION EACH 25145 "$1,441.00 " 960 "$1,008.70 " $720.50 "$1,152.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310154 PHYSICIAN FEE - SURGERY PF-REMOVE FOREARM FOREIGN BODY EACH 25248 "$1,177.00 " 960 $823.90 $588.50 $941.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300098 PHYSICIAN FEE - SURGERY PF-REMOVE FOREIGN BODY EACH 10121 $492.00 960 $344.40 $246.00 $393.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337405 PHYSICIAN FEE - SURGERY PF-REMOVE FOREIGN BODY ADBOMEN EACH 49402 "$2,412.00 " 960 "$1,688.40 " "$1,206.00 " "$1,929.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346554 PHYSICIAN FEE - SURGERY PF-REMOVE FOREIGN BODY BRAIN EACH 61570 "$5,647.00 " 960 "$3,952.90 " "$2,823.50 " "$4,517.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320914 PHYSICIAN FEE - SURGERY PF-REMOVE FOREIGN BODY LARYNX EACH 31511 $361.00 960 $252.70 $180.50 $288.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321151 PHYSICIAN FEE - SURGERY PF-REMOVE FOREIGN BODY LARYNX EACH 31577 $359.00 960 $251.30 $179.50 $287.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333495 PHYSICIAN FEE - SURGERY PF-REMOVE GASTRIC PORT OPEN EACH 43887 $934.00 960 $653.80 $467.00 $747.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329840 PHYSICIAN FEE - SURGERY PF-REMOVE GROIN LYMPH NODES EACH 38760 "$2,321.00 " 960 "$1,624.70 " "$1,160.50 " "$1,856.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329857 PHYSICIAN FEE - SURGERY PF-REMOVE GROIN LYMPH NODES EACH 38765 "$3,633.00 " 960 "$2,543.10 " "$1,816.50 " "$2,906.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311616 PHYSICIAN FEE - SURGERY PF-REMOVE HAND BONE LESION EACH 26200 "$1,240.00 " 960 $868.00 $620.00 $992.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313331 PHYSICIAN FEE - SURGERY PF-REMOVE HIP BONE LES DEEP EACH 27066 "$2,243.00 " 960 "$1,570.10 " "$1,121.50 " "$1,794.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313323 PHYSICIAN FEE - SURGERY PF-REMOVE HIP BONE LES SUPER EACH 27065 "$1,438.00 " 960 "$1,006.60 " $719.00 "$1,150.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313422 PHYSICIAN FEE - SURGERY PF-REMOVE HIP FOREIGN BODY EACH 27086 $462.00 960 $323.40 $231.00 $369.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313430 PHYSICIAN FEE - SURGERY PF-REMOVE HIP FOREIGN BODY EACH 27087 "$1,719.00 " 960 "$1,203.30 " $859.50 "$1,375.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302839 PHYSICIAN FEE - SURGERY PF-REMOVE HIP PRESSURE SORE EACH 15940 "$1,958.00 " 960 "$1,370.60 " $979.00 "$1,566.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302847 PHYSICIAN FEE - SURGERY PF-REMOVE HIP PRESSURE SORE EACH 15941 "$2,520.00 " 960 "$1,764.00 " "$1,260.00 " "$2,016.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302854 PHYSICIAN FEE - SURGERY PF-REMOVE HIP PRESSURE SORE EACH 15944 "$2,526.00 " 960 "$1,768.20 " "$1,263.00 " "$2,020.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302862 PHYSICIAN FEE - SURGERY PF-REMOVE HIP PRESSURE SORE EACH 15945 "$2,760.00 " 960 "$1,932.00 " "$1,380.00 " "$2,208.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302870 PHYSICIAN FEE - SURGERY PF-REMOVE HIP PRESSURE SORE EACH 15946 "$4,410.00 " 960 "$3,087.00 " "$2,205.00 " "$3,528.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307853 PHYSICIAN FEE - SURGERY PF-REMOVE HUMERUS LESION EACH 23174 "$2,107.00 " 960 "$1,474.90 " "$1,053.50 " "$1,685.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307887 PHYSICIAN FEE - SURGERY PF-REMOVE HUMERUS LESION EACH 23184 "$2,042.00 " 960 "$1,429.40 " "$1,021.00 " "$1,633.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308729 PHYSICIAN FEE - SURGERY PF-REMOVE HUMERUS LESION EACH 24110 "$1,631.00 " 960 "$1,141.70 " $815.50 "$1,304.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353659 PHYSICIAN FEE - SURGERY PF-REMOVE IMPACTED EAR WAX EACH 69210 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357551 PHYSICIAN FEE - SURGERY PF-REMOVE IMPACTED EAR WAX UNI EACH 69209 $41.00 960 $28.70 $20.50 $32.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351448 PHYSICIAN FEE - SURGERY PF-REMOVE IMPLANT OF EYE EACH 65920 "$2,023.00 " 960 "$1,416.10 " "$1,011.50 " "$1,618.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335557 PHYSICIAN FEE - SURGERY PF-REMOVE IN/EX HEM GROUPS 2+ EACH 46260 "$1,319.00 " 960 $923.30 $659.50 "$1,055.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335532 PHYSICIAN FEE - SURGERY PF-REMOVE IN/EX HEM GRP & FISS EACH 46257 "$1,110.00 " 960 $777.00 $555.00 $888.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346166 PHYSICIAN FEE - SURGERY PF-REMOVE INFECTED SKULL BONE EACH 61501 "$3,238.00 " 960 "$2,266.60 " "$1,619.00 " "$2,590.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354301 PHYSICIAN FEE - SURGERY PF-REMOVE INNER EAR EACH 69905 "$2,442.00 " 960 "$1,709.40 " "$1,221.00 " "$1,953.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354319 PHYSICIAN FEE - SURGERY PF-REMOVE INNER EAR & MASTOID EACH 69910 "$2,647.00 " 960 "$1,852.90 " "$1,323.50 " "$2,117.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354376 PHYSICIAN FEE - SURGERY PF-REMOVE INNER EAR LESION EACH 69970 "$5,688.00 " 960 "$3,981.60 " "$2,844.00 " "$4,550.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335524 PHYSICIAN FEE - SURGERY PF-REMOVE INT/EXT HEM 1 GROUP EACH 46255 $967.00 960 $676.90 $483.50 $773.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325285 PHYSICIAN FEE - SURGERY PF-REMOVE INTRA-AORTIC BALLOON EACH 33974 "$2,468.00 " 960 "$1,727.60 " "$1,234.00 " "$1,974.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344088 PHYSICIAN FEE - SURGERY PF-REMOVE INTRAUTERINE DEVICE EACH 58301 $182.00 960 $127.40 $91.00 $145.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351646 PHYSICIAN FEE - SURGERY PF-REMOVE IRIS AND LESION EACH 66600 "$2,309.00 " 960 "$1,616.30 " "$1,154.50 " "$1,847.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304926 PHYSICIAN FEE - SURGERY PF-REMOVE JAW JOINT CARTILAGE EACH 21060 "$2,043.00 " 960 "$1,430.10 " "$1,021.50 " "$1,634.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338387 PHYSICIAN FEE - SURGERY PF-REMOVE KIDNEY LIVING DONOR EACH 50320 "$4,289.00 " 960 "$3,002.30 " "$2,144.50 " "$3,431.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338296 PHYSICIAN FEE - SURGERY PF-REMOVE KIDNEY OPEN EACH 50220 "$2,843.00 " 960 "$1,990.10 " "$1,421.50 " "$2,274.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314461 PHYSICIAN FEE - SURGERY PF-REMOVE KNEE CYST EACH 27347 "$1,452.00 " 960 "$1,016.40 " $726.00 "$1,161.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314404 PHYSICIAN FEE - SURGERY PF-REMOVE KNEE JOINT LINING EACH 27334 "$1,893.00 " 960 "$1,325.10 " $946.50 "$1,514.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314412 PHYSICIAN FEE - SURGERY PF-REMOVE KNEE JOINT LINING EACH 27335 "$2,115.00 " 960 "$1,480.50 " "$1,057.50 " "$1,692.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350267 PHYSICIAN FEE - SURGERY PF-REMOVE LIMB NERVE LESION EACH 64782 "$1,225.00 " 960 $857.50 $612.50 $980.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315799 PHYSICIAN FEE - SURGERY PF-REMOVE LOWER LEG BONE LES EACH 27635 "$1,580.00 " 960 "$1,106.00 " $790.00 "$1,264.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307473 PHYSICIAN FEE - SURGERY PF-REMOVE LUMB ARTIF DISC EACH 22865 "$6,801.00 " 960 "$4,760.70 " "$3,400.50 " "$5,440.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325103 PHYSICIAN FEE - SURGERY PF-REMOVE LUNG ARTERY EMBOLI EACH 33910 "$7,257.00 " 960 "$5,079.90 " "$3,628.50 " "$5,805.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325111 PHYSICIAN FEE - SURGERY PF-REMOVE LUNG ARTERY EMBOLI EACH 33915 "$3,815.00 " 960 "$2,670.50 " "$1,907.50 " "$3,052.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321953 PHYSICIAN FEE - SURGERY PF-REMOVE LUNG FOREIGN BODY EACH 32151 "$2,818.00 " 960 "$1,972.60 " "$1,409.00 " "$2,254.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304876 PHYSICIAN FEE - SURGERY PF-REMOVE MANDIBLE CYST COMPLX EACH 21046 "$2,579.00 " 960 "$1,805.30 " "$1,289.50 " "$2,063.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354137 PHYSICIAN FEE - SURGERY PF-REMOVE MASTOID AIR CELLS EACH 69670 "$2,509.00 " 960 "$1,756.30 " "$1,254.50 " "$2,007.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353808 PHYSICIAN FEE - SURGERY PF-REMOVE MASTOID STRUCTURES EACH 69505 "$3,236.00 " 960 "$2,265.20 " "$1,618.00 " "$2,588.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304892 PHYSICIAN FEE - SURGERY PF-REMOVE MAXILLA CYST COMPLEX EACH 21048 "$2,603.00 " 960 "$1,822.10 " "$1,301.50 " "$2,082.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300189 PHYSICIAN FEE - SURGERY PF-REMOVE MESH FROM ABD WALL EACH 11008 $771.00 960 $539.70 $385.50 $616.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354145 PHYSICIAN FEE - SURGERY PF-REMOVE MIDDLE EAR NERVE EACH 69676 "$2,214.00 " 960 "$1,549.80 " "$1,107.00 " "$1,771.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341829 PHYSICIAN FEE - SURGERY PF-REMOVE MUTI-COMP PENIS PROS EACH 54406 "$1,945.00 " 960 "$1,361.50 " $972.50 "$1,556.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300932 PHYSICIAN FEE - SURGERY PF-REMOVE NAIL PLATE ADD-ON EACH 11732 $44.00 960 $30.80 $22.00 $35.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320005 PHYSICIAN FEE - SURGERY PF-REMOVE NASAL FOREIGN BODY EACH 30300 $324.00 960 $226.80 $162.00 $259.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320013 PHYSICIAN FEE - SURGERY PF-REMOVE NASAL FOREIGN BODY EACH 30310 $549.00 960 $384.30 $274.50 $439.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320021 PHYSICIAN FEE - SURGERY PF-REMOVE NASAL FOREIGN BODY EACH 30320 "$1,288.00 " 960 $901.60 $644.00 "$1,030.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350283 PHYSICIAN FEE - SURGERY PF-REMOVE NERVE LESION EACH 64784 "$1,989.00 " 960 "$1,392.30 " $994.50 "$1,591.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330939 PHYSICIAN FEE - SURGERY PF-REMOVE PALATE/LESION EACH 42120 "$2,643.00 " 960 "$1,850.10 " "$1,321.50 " "$2,114.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306715 PHYSICIAN FEE - SURGERY PF-REMOVE PART LUMBAR VERTEBRA EACH 22102 "$2,123.00 " 960 "$1,486.10 " "$1,061.50 " "$1,698.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306756 PHYSICIAN FEE - SURGERY PF-REMOVE PART LUMBAR VERTEBRA EACH 22114 "$3,374.00 " 960 "$2,361.80 " "$1,687.00 " "$2,699.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306699 PHYSICIAN FEE - SURGERY PF-REMOVE PART NECK VERTEBRA EACH 22100 "$2,784.00 " 960 "$1,948.80 " "$1,392.00 " "$2,227.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306731 PHYSICIAN FEE - SURGERY PF-REMOVE PART NECK VERTEBRA EACH 22110 "$3,059.00 " 960 "$2,141.30 " "$1,529.50 " "$2,447.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353832 PHYSICIAN FEE - SURGERY PF-REMOVE PART TEMPORAL BONE EACH 69535 "$7,087.00 " 960 "$4,960.90 " "$3,543.50 " "$5,669.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306707 PHYSICIAN FEE - SURGERY PF-REMOVE PART THORAX VERTEBRA EACH 22101 "$2,501.00 " 960 "$1,750.70 " "$1,250.50 " "$2,000.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306749 PHYSICIAN FEE - SURGERY PF-REMOVE PART THORAX VERTEBRA EACH 22112 "$3,374.00 " 960 "$2,361.80 " "$1,687.00 " "$2,699.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329865 PHYSICIAN FEE - SURGERY PF-REMOVE PELVIS LYMPH NODES EACH 38770 "$2,180.00 " 960 "$1,526.00 " "$1,090.00 " "$1,744.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341431 PHYSICIAN FEE - SURGERY PF-REMOVE PENIS & NODES EACH 54130 "$3,164.00 " 960 "$2,214.80 " "$1,582.00 " "$2,531.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341449 PHYSICIAN FEE - SURGERY PF-REMOVE PENIS & NODES EACH 54135 "$3,999.00 " 960 "$2,799.30 " "$1,999.50 " "$3,199.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331465 PHYSICIAN FEE - SURGERY PF-REMOVE PHARYNX FOREIGN BODY EACH 42809 $344.00 960 $240.80 $172.00 $275.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347560 PHYSICIAN FEE - SURGERY PF-REMOVE PITUIT TUMOR W/SCOPE EACH 62165 "$4,369.00 " 960 "$3,058.30 " "$2,184.50 " "$3,495.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340649 PHYSICIAN FEE - SURGERY PF-REMOVE PROSTATE REGROWTH EACH 52630 "$1,078.00 " 960 $754.60 $539.00 $862.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325160 PHYSICIAN FEE - SURGERY PF-REMOVE PULMONARY SHUNT EACH 33924 $802.00 960 $561.40 $401.00 $641.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502397 PHYSICIAN FEE - SURGERY PF-REMOVE PULSE GEN ONLY ISDSS EACH 0682T $490.00 960 $343.00 $245.00 $392.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323249 PHYSICIAN FEE - SURGERY PF-REMOVE PULSE GENERATOR EACH 33241 $587.00 960 $410.90 $293.50 $469.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308802 PHYSICIAN FEE - SURGERY PF-REMOVE RADIUS BONE LESION EACH 24136 "$1,747.00 " 960 "$1,222.90 " $873.50 "$1,397.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308901 PHYSICIAN FEE - SURGERY PF-REMOVE RADIUS HEAD IMPLANT EACH 24164 "$2,002.00 " 960 "$1,401.40 " "$1,001.00 " "$1,601.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335367 PHYSICIAN FEE - SURGERY PF-REMOVE RECTAL OBSTRUCTION EACH 45915 $622.00 960 $435.40 $311.00 $497.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334717 PHYSICIAN FEE - SURGERY PF-REMOVE RECTUM W/RESERVOIR EACH 45119 "$4,996.00 " 960 "$3,497.20 " "$2,498.00 " "$3,996.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302771 PHYSICIAN FEE - SURGERY PF-REMOVE SACRUM PRESSURE SORE EACH 15931 "$1,961.00 " 960 "$1,372.70 " $980.50 "$1,568.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302789 PHYSICIAN FEE - SURGERY PF-REMOVE SACRUM PRESSURE SORE EACH 15933 "$2,403.00 " 960 "$1,682.10 " "$1,201.50 " "$1,922.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302797 PHYSICIAN FEE - SURGERY PF-REMOVE SACRUM PRESSURE SORE EACH 15934 "$2,669.00 " 960 "$1,868.30 " "$1,334.50 " "$2,135.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302805 PHYSICIAN FEE - SURGERY PF-REMOVE SACRUM PRESSURE SORE EACH 15935 "$3,124.00 " 960 "$2,186.80 " "$1,562.00 " "$2,499.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302813 PHYSICIAN FEE - SURGERY PF-REMOVE SACRUM PRESSURE SORE EACH 15936 "$2,478.00 " 960 "$1,734.60 " "$1,239.00 " "$1,982.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302821 PHYSICIAN FEE - SURGERY PF-REMOVE SACRUM PRESSURE SORE EACH 15937 "$2,839.00 " 960 "$1,987.30 " "$1,419.50 " "$2,271.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307846 PHYSICIAN FEE - SURGERY PF-REMOVE SHOULDER BLADE LES EACH 23172 "$1,577.00 " 960 "$1,103.90 " $788.50 "$1,261.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307879 PHYSICIAN FEE - SURGERY PF-REMOVE SHOULDER BLADE LES EACH 23182 "$1,851.00 " 960 "$1,295.70 " $925.50 "$1,480.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307762 PHYSICIAN FEE - SURGERY PF-REMOVE SHOULDER BONE PART EACH 23130 "$1,702.00 " 960 "$1,191.40 " $851.00 "$1,361.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354574 PHYSICIAN FEE - SURGERY PF-REMOVE SHOULDER FB DEEP EACH 23333 "$1,306.00 " 960 $914.20 $653.00 "$1,044.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307713 PHYSICIAN FEE - SURGERY PF-REMOVE SHOULDER JT LINING EACH 23105 "$1,768.00 " 960 "$1,237.60 " $884.00 "$1,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350234 PHYSICIAN FEE - SURGERY PF-REMOVE SKIN NERVE LESION EACH 64774 "$1,177.00 " 960 $823.90 $588.50 $941.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350317 PHYSICIAN FEE - SURGERY PF-REMOVE SKIN NERVE LESION EACH 64788 "$1,123.00 " 960 $786.10 $561.50 $898.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347453 PHYSICIAN FEE - SURGERY PF-REMOVE SKULL PLATE/FLAP EACH 62142 "$2,650.00 " 960 "$1,855.00 " "$1,325.00 " "$2,120.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342447 PHYSICIAN FEE - SURGERY PF-REMOVE SPERM DUCT POUCH EACH 55650 "$1,910.00 " 960 "$1,337.00 " $955.00 "$1,528.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342454 PHYSICIAN FEE - SURGERY PF-REMOVE SPERM POUCH LESION EACH 55680 $925.00 960 $647.50 $462.50 $740.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347966 PHYSICIAN FEE - SURGERY PF-REMOVE SPINAL CANAL CATH EACH 62355 $767.00 960 $536.90 $383.50 $613.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348949 PHYSICIAN FEE - SURGERY PF-REMOVE SPINAL CORD LESION EACH 63600 "$3,295.00 " 960 "$2,306.50 " "$1,647.50 " "$2,636.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348238 PHYSICIAN FEE - SURGERY PF-REMOVE SPINAL LAMINA ADD-ON EACH 63048 $614.00 960 $429.80 $307.00 $491.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349020 PHYSICIAN FEE - SURGERY PF-REMOVE SPINE ELTRD PLATE EACH 63662 "$2,483.00 " 960 "$1,738.10 " "$1,241.50 " "$1,986.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348006 PHYSICIAN FEE - SURGERY PF-REMOVE SPINE INF DEVICE EACH 62365 $836.00 960 $585.20 $418.00 $668.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350382 PHYSICIAN FEE - SURGERY PF-REMOVE SYMPATHETIC NERVES EACH 64818 "$2,145.00 " 960 "$1,501.50 " "$1,072.50 " "$1,716.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350358 PHYSICIAN FEE - SURGERY PF-REMOVE SYMPATHETIC NERVES EACH 64802 "$2,514.00 " 960 "$1,759.80 " "$1,257.00 " "$2,011.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350366 PHYSICIAN FEE - SURGERY PF-REMOVE SYMPATHETIC NERVES EACH 64804 "$3,575.00 " 960 "$2,502.50 " "$1,787.50 " "$2,860.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350374 PHYSICIAN FEE - SURGERY PF-REMOVE SYMPATHETIC NERVES EACH 64809 "$3,273.00 " 960 "$2,291.10 " "$1,636.50 " "$2,618.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350390 PHYSICIAN FEE - SURGERY PF-REMOVE SYMPATHETIC NERVES EACH 64820 "$1,768.00 " 960 "$1,237.60 " $884.00 "$1,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350408 PHYSICIAN FEE - SURGERY PF-REMOVE SYMPATHETIC NERVES EACH 64821 "$1,923.00 " 960 "$1,346.10 " $961.50 "$1,538.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350416 PHYSICIAN FEE - SURGERY PF-REMOVE SYMPATHETIC NERVES EACH 64822 "$1,923.00 " 960 "$1,346.10 " $961.50 "$1,538.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350424 PHYSICIAN FEE - SURGERY PF-REMOVE SYMPATHETIC NERVES EACH 64823 "$2,181.00 " 960 "$1,526.70 " "$1,090.50 " "$1,744.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353352 PHYSICIAN FEE - SURGERY PF-REMOVE TEAR GLAN FRONTAL EACH 68540 "$2,516.00 " 960 "$1,761.20 " "$1,258.00 " "$2,012.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353360 PHYSICIAN FEE - SURGERY PF-REMOVE TEAR GLAND OSTEOTOMY EACH 68550 "$3,133.00 " 960 "$2,193.10 " "$1,566.50 " "$2,506.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311574 PHYSICIAN FEE - SURGERY PF-REMOVE TENDON SHEATH LESION EACH 26160 $867.00 960 $606.90 $433.50 $693.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302888 PHYSICIAN FEE - SURGERY PF-REMOVE THIGH PRESSURE SORE EACH 15950 "$1,720.00 " 960 "$1,204.00 " $860.00 "$1,376.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302896 PHYSICIAN FEE - SURGERY PF-REMOVE THIGH PRESSURE SORE EACH 15951 "$2,427.00 " 960 "$1,698.90 " "$1,213.50 " "$1,941.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302904 PHYSICIAN FEE - SURGERY PF-REMOVE THIGH PRESSURE SORE EACH 15952 "$2,479.00 " 960 "$1,735.30 " "$1,239.50 " "$1,983.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302912 PHYSICIAN FEE - SURGERY PF-REMOVE THIGH PRESSURE SORE EACH 15953 "$2,730.00 " 960 "$1,911.00 " "$1,365.00 " "$2,184.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302920 PHYSICIAN FEE - SURGERY PF-REMOVE THIGH PRESSURE SORE EACH 15956 "$3,263.00 " 960 "$2,284.10 " "$1,631.50 " "$2,610.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302938 PHYSICIAN FEE - SURGERY PF-REMOVE THIGH PRESSURE SORE EACH 15958 "$3,203.00 " 960 "$2,242.10 " "$1,601.50 " "$2,562.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329824 PHYSICIAN FEE - SURGERY PF-REMOVE THORACIC LYMPH NODES EACH 38746 $604.00 960 $422.80 $302.00 $483.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345598 PHYSICIAN FEE - SURGERY PF-REMOVE THYROID DUCT LESION EACH 60280 "$1,224.00 " 960 $856.80 $612.00 $979.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345606 PHYSICIAN FEE - SURGERY PF-REMOVE THYROID DUCT LESION EACH 60281 "$1,603.00 " 960 "$1,122.10 " $801.50 "$1,282.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345481 PHYSICIAN FEE - SURGERY PF-REMOVE THYROID LESION EACH 60200 "$1,848.00 " 960 "$1,293.60 " $924.00 "$1,478.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301153 PHYSICIAN FEE - SURGERY PF-REMOVE TISSUE EXPANDER(S) EACH 11971 "$1,496.00 " 960 "$1,047.20 " $748.00 "$1,196.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331499 PHYSICIAN FEE - SURGERY PF-REMOVE TONSILS AND ADENOIDS EACH 42820 $786.00 960 $550.20 $393.00 $628.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331507 PHYSICIAN FEE - SURGERY PF-REMOVE TONSILS AND ADENOIDS EACH 42821 $820.00 960 $574.00 $410.00 $656.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338478 PHYSICIAN FEE - SURGERY PF-REMOVE TRANSPLANTED KIDNEY EACH 50370 "$3,416.00 " 960 "$2,391.20 " "$1,708.00 " "$2,732.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339500 PHYSICIAN FEE - SURGERY PF-REMOVE URETER CALCULUS EACH 51065 "$1,545.00 " 960 "$1,081.50 " $772.50 "$1,236.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338502 PHYSICIAN FEE - SURGERY PF-REMOVE URETER STENT PERCUT EACH 50384 $589.00 960 $412.30 $294.50 $471.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341027 PHYSICIAN FEE - SURGERY PF-REMOVE URO SPHINCTER EACH 53446 "$1,709.00 " 960 "$1,196.30 " $854.50 "$1,367.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344989 PHYSICIAN FEE - SURGERY PF-REMOVE UTERUS LESION EACH 59100 "$2,490.00 " 960 "$1,743.00 " "$1,245.00 " "$1,992.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342884 PHYSICIAN FEE - SURGERY PF-REMOVE VAGINA GLAND LESION EACH 56740 $859.00 960 $601.30 $429.50 $687.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343106 PHYSICIAN FEE - SURGERY PF-REMOVE VAGINA LESION EACH 57130 $469.00 960 $328.30 $234.50 $375.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343114 PHYSICIAN FEE - SURGERY PF-REMOVE VAGINA LESION EACH 57135 $509.00 960 $356.30 $254.50 $407.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343072 PHYSICIAN FEE - SURGERY PF-REMOVE VAGINA TISSUE COMPL EACH 57111 "$4,730.00 " 960 "$3,311.00 " "$2,365.00 " "$3,784.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343049 PHYSICIAN FEE - SURGERY PF-REMOVE VAGINA TISSUE PART EACH 57107 "$3,978.00 " 960 "$2,784.60 " "$1,989.00 " "$3,182.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343064 PHYSICIAN FEE - SURGERY PF-REMOVE VAGINA WALL COMPLETE EACH 57110 "$2,466.00 " 960 "$1,726.20 " "$1,233.00 " "$1,972.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343031 PHYSICIAN FEE - SURGERY PF-REMOVE VAGINA WALL PARTIAL EACH 57106 "$1,454.00 " 960 "$1,017.80 " $727.00 "$1,163.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343528 PHYSICIAN FEE - SURGERY PF-REMOVE VAGINAL FOREIGN BODY EACH 57415 $475.00 960 $332.50 $237.50 $380.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349665 PHYSICIAN FEE - SURGERY PF-REMOVE VAGUS N ELTRD EACH 64570 "$2,189.00 " 960 "$1,532.30 " "$1,094.50 " "$1,751.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321086 PHYSICIAN FEE - SURGERY PF-REMOVE VC LESION SCOPE/GRFT EACH 31546 "$1,469.00 " 960 "$1,028.30 " $734.50 "$1,175.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321078 PHYSICIAN FEE - SURGERY PF-REMOVE VC LESION W/SCOPE EACH 31545 $968.00 960 $677.60 $484.00 $774.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353733 PHYSICIAN FEE - SURGERY PF-REMOVE VENTILATING TUBE EACH 69424 $160.00 960 $112.00 $80.00 $128.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325319 PHYSICIAN FEE - SURGERY PF-REMOVE VENTRICULAR DEVICE EACH 33977 "$3,127.00 " 960 "$2,188.90 " "$1,563.50 " "$2,501.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325327 PHYSICIAN FEE - SURGERY PF-REMOVE VENTRICULAR DEVICE EACH 33978 "$3,687.00 " 960 "$2,580.90 " "$1,843.50 " "$2,949.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348360 PHYSICIAN FEE - SURGERY PF-REMOVE VERTEBRAL BODY ADDON EACH 63082 $779.00 960 $545.30 $389.50 $623.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348386 PHYSICIAN FEE - SURGERY PF-REMOVE VERTEBRAL BODY ADDON EACH 63086 $562.00 960 $393.40 $281.00 $449.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348402 PHYSICIAN FEE - SURGERY PF-REMOVE VERTEBRAL BODY ADDON EACH 63088 $761.00 960 $532.70 $380.50 $608.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348428 PHYSICIAN FEE - SURGERY PF-REMOVE VERTEBRAL BODY ADDON EACH 63091 $500.00 960 $350.00 $250.00 $400.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348451 PHYSICIAN FEE - SURGERY PF-REMOVE VERTEBRAL BODY ADDON EACH 63103 $857.00 960 $599.90 $428.50 $685.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348931 PHYSICIAN FEE - SURGERY PF-REMOVE VERTEBRAL BODY ADDON EACH 63308 $949.00 960 $664.30 $474.50 $759.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321763 PHYSICIAN FEE - SURGERY PF-REMOVE WINDPIPE LESION EACH 31785 "$2,893.00 " 960 "$2,025.10 " "$1,446.50 " "$2,314.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321771 PHYSICIAN FEE - SURGERY PF-REMOVE WINDPIPE LESION EACH 31786 "$4,047.00 " 960 "$2,832.90 " "$2,023.50 " "$3,237.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310667 PHYSICIAN FEE - SURGERY PF-REMOVE WRIST JOINT IMPLANT EACH 25449 "$2,824.00 " 960 "$1,976.80 " "$1,412.00 " "$2,259.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309909 PHYSICIAN FEE - SURGERY PF-REMOVE WRIST JOINT LINING EACH 25105 "$1,339.00 " 960 $937.30 $669.50 "$1,071.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311533 PHYSICIAN FEE - SURGERY PF-REMOVE WRIST JOINT LINING EACH 26130 "$1,297.00 " 960 $907.90 $648.50 "$1,037.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309917 PHYSICIAN FEE - SURGERY PF-REMOVE WRIST JT CARTILAGE EACH 25107 "$1,692.00 " 960 "$1,184.40 " $846.00 "$1,353.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309933 PHYSICIAN FEE - SURGERY PF-REMOVE WRIST TENDON LESION EACH 25110 $951.00 960 $665.70 $475.50 $760.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309941 PHYSICIAN FEE - SURGERY PF-REMOVE WRIST TENDON LESION EACH 25111 $892.00 960 $624.40 $446.00 $713.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309966 PHYSICIAN FEE - SURGERY PF-REMOVE WRIST/FOREARM LESION EACH 25115 "$2,073.00 " 960 "$1,451.10 " "$1,036.50 " "$1,658.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309974 PHYSICIAN FEE - SURGERY PF-REMOVE WRIST/FOREARM LESION EACH 25116 "$1,657.00 " 960 "$1,159.90 " $828.50 "$1,325.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323124 PHYSICIAN FEE - SURGERY PF-REMOVE&REPLACE PM GEN SINGL EACH 33227 $932.00 960 $652.40 $466.00 $745.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308737 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT BONE LESION EACH 24115 "$2,038.00 " 960 "$1,426.60 " "$1,019.00 " "$1,630.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308745 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT BONE LESION EACH 24116 "$2,375.00 " 960 "$1,662.50 " "$1,187.50 " "$1,900.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308760 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT BONE LESION EACH 24125 "$1,721.00 " 960 "$1,204.70 " $860.50 "$1,376.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308778 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT BONE LESION EACH 24126 "$1,797.00 " 960 "$1,257.90 " $898.50 "$1,437.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311624 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT BONE LESION EACH 26205 "$1,671.00 " 960 "$1,169.70 " $835.50 "$1,336.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311640 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT FINGER LESION EACH 26215 "$1,569.00 " 960 "$1,098.30 " $784.50 "$1,255.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317126 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT FOOT LESION EACH 28103 "$1,013.00 " 960 $709.10 $506.50 $810.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310014 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT FOREARM LESION EACH 25125 "$1,646.00 " 960 "$1,152.20 " $823.00 "$1,316.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310022 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT FOREARM LESION EACH 25126 "$1,658.00 " 960 "$1,160.60 " $829.00 "$1,326.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313349 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT HIP BONE LES EACH 27067 "$2,853.00 " 960 "$1,997.10 " "$1,426.50 " "$2,282.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315807 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT LEG BONE LES EACH 27637 "$2,045.00 " 960 "$1,431.50 " "$1,022.50 " "$1,636.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315815 PHYSICIAN FEE - SURGERY PF-REMOVE/GRAFT LEG BONE LES EACH 27638 "$2,024.00 " 960 "$1,416.80 " "$1,012.00 " "$1,619.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301203 PHYSICIAN FEE - SURGERY PF-REMOVE/INSERT DRUG IMPLANT EACH 11983 $284.00 960 $198.80 $142.00 $227.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354160 PHYSICIAN FEE - SURGERY PF-REMOVE/REPAIR HEARING AID EACH 69711 "$2,232.00 " 960 "$1,562.40 " "$1,116.00 " "$1,785.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341845 PHYSICIAN FEE - SURGERY PF-REMOVE/REPLACE PENIS PROSTH EACH 54410 "$2,293.00 " 960 "$1,605.10 " "$1,146.50 " "$1,834.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341035 PHYSICIAN FEE - SURGERY PF-REMOVE/REPLACE UR SPHINCTER EACH 53447 "$2,139.00 " 960 "$1,497.30 " "$1,069.50 " "$1,711.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340995 PHYSICIAN FEE - SURGERY PF-REMOVE/REVISE MALE SLING EACH 53442 "$2,087.00 " 960 "$1,460.90 " "$1,043.50 " "$1,669.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308067 PHYSICIAN FEE - SURGERY PF-REMOVE/TRANSPLANT TENDON EACH 23440 "$2,091.00 " 960 "$1,463.70 " "$1,045.50 " "$1,672.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321938 PHYSICIAN FEE - SURGERY PF-REMOVE/TREAT LUNG LESIONS EACH 32141 "$4,259.00 " 960 "$2,981.30 " "$2,129.50 " "$3,407.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323132 PHYSICIAN FEE - SURGERY PF-REMV&REPLC PM GEN DUAL LEAD EACH 33228 $973.00 960 $681.10 $486.50 $778.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341886 PHYSICIAN FEE - SURGERY PF-REMV/REPLC PENIS PROS COMPL EACH 54417 "$2,387.00 " 960 "$1,670.90 " "$1,193.50 " "$1,909.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338130 PHYSICIAN FEE - SURGERY PF-RENAL ABSCESS OPEN DRAIN EACH 50020 "$2,693.00 " 960 "$1,885.10 " "$1,346.50 " "$2,154.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338288 PHYSICIAN FEE - SURGERY PF-RENAL BIOPSY OPEN EACH 50205 "$2,125.00 " 960 "$1,487.50 " "$1,062.50 " "$1,700.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338833 PHYSICIAN FEE - SURGERY PF-RENAL SCOPE W/TUMOR RESECT EACH 50562 "$1,525.00 " 960 "$1,067.50 " $762.50 "$1,220.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344138 PHYSICIAN FEE - SURGERY PF-REOPEN FALLOPIAN TUBE EACH 58345 $790.00 960 $553.00 $395.00 $632.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344153 PHYSICIAN FEE - SURGERY PF-REOPEN FALLOPIAN TUBE EACH 58350 $255.00 960 $178.50 $127.50 $204.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337140 PHYSICIAN FEE - SURGERY PF-REOPENING OF ABDOMEN EACH 49002 "$2,939.00 " 960 "$2,057.30 " "$1,469.50 " "$2,351.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327257 PHYSICIAN FEE - SURGERY PF-REOPERATION BYPASS GRAFT EACH 35700 $429.00 960 $300.30 $214.50 $343.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326424 PHYSICIAN FEE - SURGERY PF-REOPERATION CAROTID ADD-ON EACH 35390 $448.00 960 $313.60 $224.00 $358.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335789 PHYSICIAN FEE - SURGERY PF-REP ANORECTAL FIST W/PLUG EACH 46707 "$1,404.00 " 960 $982.80 $702.00 "$1,123.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325921 PHYSICIAN FEE - SURGERY PF-REP ARTERY RUPTURE SPLEEN EACH 35112 "$4,626.00 " 960 "$3,238.20 " "$2,313.00 " "$3,700.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334451 PHYSICIAN FEE - SURGERY PF-REP BOWEL-BLADDER FISTULA EACH 44660 "$3,700.00 " 960 "$2,590.00 " "$1,850.00 " "$2,960.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334469 PHYSICIAN FEE - SURGERY PF-REP BOWEL-BLADDER FISTULA EACH 44661 "$4,273.00 " 960 "$2,991.10 " "$2,136.50 " "$3,418.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352842 PHYSICIAN FEE - SURGERY PF-REP EYELID DEF - EXTERNAL EACH 67904 "$1,527.00 " 960 "$1,068.90 " $763.50 "$1,221.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352867 PHYSICIAN FEE - SURGERY PF-REP EYELID DEF - FAS-SERVAT EACH 67908 "$1,104.00 " 960 $772.80 $552.00 $883.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352818 PHYSICIAN FEE - SURGERY PF-REP EYELID DEF-BANK FASCIA EACH 67901 "$1,509.00 " 960 "$1,056.30 " $754.50 "$1,207.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310253 PHYSICIAN FEE - SURGERY PF-REP FOREARM TENDON SHEATH EACH 25275 "$1,846.00 " 960 "$1,292.20 " $923.00 "$1,476.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354111 PHYSICIAN FEE - SURGERY PF-REP MIDDLE EAR STRUCTURES EACH 69666 "$2,151.00 " 960 "$1,505.70 " "$1,075.50 " "$1,720.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354129 PHYSICIAN FEE - SURGERY PF-REP MIDDLE EAR STRUCTURES EACH 69667 "$2,161.00 " 960 "$1,512.70 " "$1,080.50 " "$1,728.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335813 PHYSICIAN FEE - SURGERY PF-REP PERF ANOPER FISTU EACH 46715 "$1,555.00 " 960 "$1,088.50 " $777.50 "$1,244.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335821 PHYSICIAN FEE - SURGERY PF-REP PERF ANOPER/VESTIB FIST EACH 46716 "$3,464.00 " 960 "$2,424.80 " "$1,732.00 " "$2,771.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335318 PHYSICIAN FEE - SURGERY PF-REP RECTOURETHRAL FISTULA EACH 45820 "$3,604.00 " 960 "$2,522.80 " "$1,802.00 " "$2,883.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333453 PHYSICIAN FEE - SURGERY PF-REP STOMACH-BOWEL FISTULA EACH 43880 "$4,568.00 " 960 "$3,197.60 " "$2,284.00 " "$3,654.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301286 PHYSICIAN FEE - SURGERY PF-REP WND SIMPL FACE 2.6-5.CM EACH 12013 $163.00 960 $114.10 $81.50 $130.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350614 PHYSICIAN FEE - SURGERY PF-REPAIR & REVISE NERVE ADDON EACH 64874 $476.00 960 $333.20 $238.00 $380.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315880 PHYSICIAN FEE - SURGERY PF-REPAIR ACHILLES TENDON EACH 27650 "$1,775.00 " 960 "$1,242.50 " $887.50 "$1,420.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335623 PHYSICIAN FEE - SURGERY PF-REPAIR ANAL FISTULA EACH 46288 "$1,514.00 " 960 "$1,059.80 " $757.00 "$1,211.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324262 PHYSICIAN FEE - SURGERY PF-REPAIR ANOMALY W/CONDUIT EACH 33608 "$5,055.00 " 960 "$3,538.50 " "$2,527.50 " "$4,044.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309032 PHYSICIAN FEE - SURGERY PF-REPAIR ARM TENDON/MUSCLE EACH 24341 "$2,056.00 " 960 "$1,439.20 " "$1,028.00 " "$1,644.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350515 PHYSICIAN FEE - SURGERY PF-REPAIR ARM/LEG NERVE EACH 64857 "$2,891.00 " 960 "$2,023.70 " "$1,445.50 " "$2,312.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324007 PHYSICIAN FEE - SURGERY PF-REPAIR ART INTRAMURAL EACH 33507 "$4,834.00 " 960 "$3,383.80 " "$2,417.00 " "$3,867.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324825 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERIAL TRUNK EACH 33786 "$6,399.00 " 960 "$4,479.30 " "$3,199.50 " "$5,119.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325863 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE AORTA EACH 35082 "$6,092.00 " 960 "$4,264.40 " "$3,046.00 " "$4,873.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325889 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE AORTA EACH 35092 "$7,325.00 " 960 "$5,127.50 " "$3,662.50 " "$5,860.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325814 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE ARM EACH 35013 "$3,564.00 " 960 "$2,494.80 " "$1,782.00 " "$2,851.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325947 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE BELLY EACH 35122 "$5,357.00 " 960 "$3,749.90 " "$2,678.50 " "$4,285.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325830 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE CHEST EACH 35022 "$4,000.00 " 960 "$2,800.00 " "$2,000.00 " "$3,200.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325905 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE GROIN EACH 35103 "$6,262.00 " 960 "$4,383.40 " "$3,131.00 " "$5,009.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325962 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE GROIN EACH 35132 "$4,626.00 " 960 "$3,238.20 " "$2,313.00 " "$3,700.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326002 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE KNEE EACH 35152 "$3,952.00 " 960 "$2,766.40 " "$1,976.00 " "$3,161.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325780 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE NECK EACH 35002 "$3,219.00 " 960 "$2,253.30 " "$1,609.50 " "$2,575.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325988 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY RUPTURE THIGH EACH 35142 "$3,714.00 " 960 "$2,599.80 " "$1,857.00 " "$2,971.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323991 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY TRANSLOCATION EACH 33506 "$5,769.00 " 960 "$4,038.30 " "$2,884.50 " "$4,615.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323983 PHYSICIAN FEE - SURGERY PF-REPAIR ARTERY W/TUNNEL EACH 33505 "$5,793.00 " 960 "$4,055.10 " "$2,896.50 " "$4,634.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308059 PHYSICIAN FEE - SURGERY PF-REPAIR BICEPS TENDON EACH 23430 "$2,046.00 " 960 "$1,432.20 " "$1,023.00 " "$1,636.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343221 PHYSICIAN FEE - SURGERY PF-REPAIR BLADDER & VAGINA EACH 57240 "$1,665.00 " 960 "$1,165.50 " $832.50 "$1,332.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343361 PHYSICIAN FEE - SURGERY PF-REPAIR BLADDER & VAGINA EACH 57289 "$2,168.00 " 960 "$1,517.60 " "$1,084.00 " "$1,734.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343353 PHYSICIAN FEE - SURGERY PF-REPAIR BLADDER DEFECT EACH 57288 "$2,013.00 " 960 "$1,409.10 " "$1,006.50 " "$1,610.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339989 PHYSICIAN FEE - SURGERY PF-REPAIR BLADDER NECK EACH 51845 "$1,549.00 " 960 "$1,084.30 " $774.50 "$1,239.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340029 PHYSICIAN FEE - SURGERY PF-REPAIR BLADDER/VAGINA LES EACH 51900 "$2,186.00 " 960 "$1,530.20 " "$1,093.00 " "$1,748.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343478 PHYSICIAN FEE - SURGERY PF-REPAIR BLADDER-VAGINA LES EACH 57320 "$1,543.00 " 960 "$1,080.10 " $771.50 "$1,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343486 PHYSICIAN FEE - SURGERY PF-REPAIR BLADDER-VAGINA LES EACH 57330 "$2,041.00 " 960 "$1,428.70 " "$1,020.50 " "$1,632.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326010 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35180 "$2,217.00 " 960 "$1,551.90 " "$1,108.50 " "$1,773.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326028 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35182 "$5,028.00 " 960 "$3,519.60 " "$2,514.00 " "$4,022.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326036 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35184 "$2,726.00 " 960 "$1,908.20 " "$1,363.00 " "$2,180.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326044 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35188 "$3,864.00 " 960 "$2,704.80 " "$1,932.00 " "$3,091.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326051 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35189 "$4,274.00 " 960 "$2,991.80 " "$2,137.00 " "$3,419.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326069 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35190 "$2,121.00 " 960 "$1,484.70 " "$1,060.50 " "$1,696.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326077 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35201 "$1,955.00 " 960 "$1,368.50 " $977.50 "$1,564.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326085 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35206 "$2,203.00 " 960 "$1,542.10 " "$1,101.50 " "$1,762.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326093 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35207 "$2,061.00 " 960 "$1,442.70 " "$1,030.50 " "$1,648.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326101 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35211 "$3,891.00 " 960 "$2,723.70 " "$1,945.50 " "$3,112.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326119 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35216 "$5,862.00 " 960 "$4,103.40 " "$2,931.00 " "$4,689.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326127 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35221 "$4,140.00 " 960 "$2,898.00 " "$2,070.00 " "$3,312.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326135 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35226 "$2,323.00 " 960 "$1,626.10 " "$1,161.50 " "$1,858.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326143 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35231 "$3,391.00 " 960 "$2,373.70 " "$1,695.50 " "$2,712.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326150 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35236 "$2,788.00 " 960 "$1,951.60 " "$1,394.00 " "$2,230.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326168 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35241 "$3,983.00 " 960 "$2,788.10 " "$1,991.50 " "$3,186.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326176 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35246 "$4,337.00 " 960 "$3,035.90 " "$2,168.50 " "$3,469.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326184 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35251 "$4,890.00 " 960 "$3,423.00 " "$2,445.00 " "$3,912.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326192 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35256 "$2,837.00 " 960 "$1,985.90 " "$1,418.50 " "$2,269.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326200 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35261 "$2,769.00 " 960 "$1,938.30 " "$1,384.50 " "$2,215.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326218 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35266 "$2,425.00 " 960 "$1,697.50 " "$1,212.50 " "$1,940.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326226 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35271 "$3,868.00 " 960 "$2,707.60 " "$1,934.00 " "$3,094.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326234 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35276 "$4,045.00 " 960 "$2,831.50 " "$2,022.50 " "$3,236.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326242 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35281 "$4,562.00 " 960 "$3,193.40 " "$2,281.00 " "$3,649.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326259 PHYSICIAN FEE - SURGERY PF-REPAIR BLOOD VESSEL LESION EACH 35286 "$2,602.00 " 960 "$1,821.40 " "$1,301.00 " "$2,081.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334444 PHYSICIAN FEE - SURGERY PF-REPAIR BOWEL FISTULA EACH 44650 "$4,007.00 " 960 "$2,804.90 " "$2,003.50 " "$3,205.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334402 PHYSICIAN FEE - SURGERY PF-REPAIR BOWEL OPENING EACH 44620 "$2,397.00 " 960 "$1,677.90 " "$1,198.50 " "$1,917.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334410 PHYSICIAN FEE - SURGERY PF-REPAIR BOWEL OPENING EACH 44625 "$2,789.00 " 960 "$1,952.30 " "$1,394.50 " "$2,231.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334428 PHYSICIAN FEE - SURGERY PF-REPAIR BOWEL OPENING EACH 44626 "$4,439.00 " 960 "$3,107.30 " "$2,219.50 " "$3,551.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334436 PHYSICIAN FEE - SURGERY PF-REPAIR BOWEL-SKIN FISTULA EACH 44640 "$3,898.00 " 960 "$2,728.60 " "$1,949.00 " "$3,118.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347388 PHYSICIAN FEE - SURGERY PF-REPAIR BRAIN FLUID LEAKAGE EACH 62100 "$4,620.00 " 960 "$3,234.00 " "$2,310.00 " "$3,696.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322142 PHYSICIAN FEE - SURGERY PF-REPAIR BRONCHUS ADD-ON EACH 32501 $688.00 960 $481.60 $344.00 $550.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352800 PHYSICIAN FEE - SURGERY PF-REPAIR BROW DEFECT EACH 67900 "$1,300.00 " 960 $910.00 $650.00 "$1,040.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324270 PHYSICIAN FEE - SURGERY PF-REPAIR BY ENLARGEMENT EACH 33610 "$4,985.00 " 960 "$3,489.50 " "$2,492.50 " "$3,988.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310493 PHYSICIAN FEE - SURGERY PF-REPAIR CARPAL BONE SHORTEN EACH 25394 "$2,166.00 " 960 "$1,516.20 " "$1,083.00 " "$1,732.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330145 PHYSICIAN FEE - SURGERY PF-REPAIR CLEFT LIP/NASAL EACH 40700 "$2,732.00 " 960 "$1,912.40 " "$1,366.00 " "$2,185.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330152 PHYSICIAN FEE - SURGERY PF-REPAIR CLEFT LIP/NASAL EACH 40701 "$3,228.00 " 960 "$2,259.60 " "$1,614.00 " "$2,582.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330160 PHYSICIAN FEE - SURGERY PF-REPAIR CLEFT LIP/NASAL EACH 40702 "$2,711.00 " 960 "$1,897.70 " "$1,355.50 " "$2,168.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330178 PHYSICIAN FEE - SURGERY PF-REPAIR CLEFT LIP/NASAL EACH 40720 "$2,781.00 " 960 "$1,946.70 " "$1,390.50 " "$2,224.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330186 PHYSICIAN FEE - SURGERY PF-REPAIR CLEFT LIP/NASAL EACH 40761 "$2,924.00 " 960 "$2,046.80 " "$1,462.00 " "$2,339.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342900 PHYSICIAN FEE - SURGERY PF-REPAIR CLITORIS EACH 56805 "$3,189.00 " 960 "$2,232.30 " "$1,594.50 " "$2,551.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360209 PHYSICIAN FEE - SURGERY PF-REPAIR CORPOREAL TEAR EACH 54437 "$1,804.00 " 960 "$1,262.80 " $902.00 "$1,443.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325848 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARM ARTERY EACH 35045 "$2,719.00 " 960 "$1,903.30 " "$1,359.50 " "$2,175.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325772 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35001 "$3,158.00 " 960 "$2,210.60 " "$1,579.00 " "$2,526.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325798 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35005 "$2,814.00 " 960 "$1,969.80 " "$1,407.00 " "$2,251.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325806 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35011 "$2,840.00 " 960 "$1,988.00 " "$1,420.00 " "$2,272.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325822 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35021 "$3,493.00 " 960 "$2,445.10 " "$1,746.50 " "$2,794.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325855 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35081 "$4,878.00 " 960 "$3,414.60 " "$2,439.00 " "$3,902.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325871 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35091 "$5,027.00 " 960 "$3,518.90 " "$2,513.50 " "$4,021.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325897 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35102 "$5,306.00 " 960 "$3,714.20 " "$2,653.00 " "$4,244.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325913 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35111 "$3,761.00 " 960 "$2,632.70 " "$1,880.50 " "$3,008.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325939 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35121 "$4,474.00 " 960 "$3,131.80 " "$2,237.00 " "$3,579.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325954 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35131 "$3,890.00 " 960 "$2,723.00 " "$1,945.00 " "$3,112.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325970 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35141 "$3,076.00 " 960 "$2,153.20 " "$1,538.00 " "$2,460.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325996 PHYSICIAN FEE - SURGERY PF-REPAIR DEFECT OF ARTERY EACH 35151 "$3,498.00 " 960 "$2,448.60 " "$1,749.00 " "$2,798.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317837 PHYSICIAN FEE - SURGERY PF-REPAIR DEFORMITY OF TOE EACH 28313 $970.00 960 $679.00 $485.00 $776.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314776 PHYSICIAN FEE - SURGERY PF-REPAIR DEGENERATED KNEECAP EACH 27418 "$2,251.00 " 960 "$1,575.70 " "$1,125.50 " "$1,800.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352115 PHYSICIAN FEE - SURGERY PF-REPAIR DETACHED RETINA EACH 67107 "$2,865.00 " 960 "$2,005.50 " "$1,432.50 " "$2,292.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329972 PHYSICIAN FEE - SURGERY PF-REPAIR DIAPHRAGM LACERATION EACH 39501 "$2,395.00 " 960 "$1,676.50 " "$1,197.50 " "$1,916.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306277 PHYSICIAN FEE - SURGERY PF-REPAIR DISLOCATED JAW EACH 21490 "$2,061.00 " 960 "$1,442.70 " "$1,030.50 " "$1,648.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324288 PHYSICIAN FEE - SURGERY PF-REPAIR DOUBLE VENTRICLE EACH 33611 "$5,478.00 " 960 "$3,834.60 " "$2,739.00 " "$4,382.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324296 PHYSICIAN FEE - SURGERY PF-REPAIR DOUBLE VENTRICLE EACH 33612 "$5,626.00 " 960 "$3,938.20 " "$2,813.00 " "$4,500.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346851 PHYSICIAN FEE - SURGERY PF-REPAIR DURA EACH 61618 "$3,752.00 " 960 "$2,626.40 " "$1,876.00 " "$3,001.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346869 PHYSICIAN FEE - SURGERY PF-REPAIR DURA EACH 61619 "$4,105.00 " 960 "$2,873.50 " "$2,052.50 " "$3,284.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353956 PHYSICIAN FEE - SURGERY PF-REPAIR EARDRUM STRUCTURES EACH 69631 "$2,361.00 " 960 "$1,652.70 " "$1,180.50 " "$1,888.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353980 PHYSICIAN FEE - SURGERY PF-REPAIR EARDRUM STRUCTURES EACH 69635 "$3,412.00 " 960 "$2,388.40 " "$1,706.00 " "$2,729.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309115 PHYSICIAN FEE - SURGERY PF-REPAIR ELBOW DEB/ATTCH OPEN EACH 24359 "$1,826.00 " 960 "$1,278.20 " $913.00 "$1,460.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309099 PHYSICIAN FEE - SURGERY PF-REPAIR ELBOW PERC EACH 24357 "$1,116.00 " 960 $781.20 $558.00 $892.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309107 PHYSICIAN FEE - SURGERY PF-REPAIR ELBOW W/DEB OPEN EACH 24358 "$1,456.00 " 960 "$1,019.20 " $728.00 "$1,164.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332539 PHYSICIAN FEE - SURGERY PF-REPAIR ESOPHAGUS & FISTULA EACH 43305 "$2,950.00 " 960 "$2,065.00 " "$1,475.00 " "$2,360.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332554 PHYSICIAN FEE - SURGERY PF-REPAIR ESOPHAGUS & FISTULA EACH 43312 "$4,477.00 " 960 "$3,133.90 " "$2,238.50 " "$3,581.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332828 PHYSICIAN FEE - SURGERY PF-REPAIR ESOPHAGUS OPENING EACH 43420 "$2,741.00 " 960 "$1,918.70 " "$1,370.50 " "$2,192.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332836 PHYSICIAN FEE - SURGERY PF-REPAIR ESOPHAGUS OPENING EACH 43425 "$4,054.00 " 960 "$2,837.80 " "$2,027.00 " "$3,243.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332802 PHYSICIAN FEE - SURGERY PF-REPAIR ESOPHAGUS WOUND EACH 43410 "$2,782.00 " 960 "$1,947.40 " "$1,391.00 " "$2,225.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332810 PHYSICIAN FEE - SURGERY PF-REPAIR ESOPHAGUS WOUND EACH 43415 "$7,253.00 " 960 "$5,077.10 " "$3,626.50 " "$5,802.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317894 PHYSICIAN FEE - SURGERY PF-REPAIR EXTRA TOE(S) EACH 28344 $732.00 960 $512.40 $366.00 $585.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352958 PHYSICIAN FEE - SURGERY PF-REPAIR EYELID DEFECT EACH 67922 $512.00 960 $358.40 $256.00 $409.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352826 PHYSICIAN FEE - SURGERY PF-REPAIR EYELID DEFECT EACH 67902 "$1,854.00 " 960 "$1,297.80 " $927.00 "$1,483.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352834 PHYSICIAN FEE - SURGERY PF-REPAIR EYELID DEFECT EACH 67903 "$1,228.00 " 960 $859.60 $614.00 $982.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352859 PHYSICIAN FEE - SURGERY PF-REPAIR EYELID DEFECT EACH 67906 "$1,290.00 " 960 $903.00 $645.00 "$1,032.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352917 PHYSICIAN FEE - SURGERY PF-REPAIR EYELID DEFECT EACH 67915 $512.00 960 $358.40 $256.00 $409.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352990 PHYSICIAN FEE - SURGERY PF-REPAIR EYELID WOUND EACH 67935 "$1,128.00 " 960 $789.60 $564.00 $902.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354236 PHYSICIAN FEE - SURGERY PF-REPAIR FACIAL NERVE EACH 69740 "$3,097.00 " 960 "$2,167.90 " "$1,548.50 " "$2,477.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354244 PHYSICIAN FEE - SURGERY PF-REPAIR FACIAL NERVE EACH 69745 "$3,299.00 " 960 "$2,309.30 " "$1,649.50 " "$2,639.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316227 PHYSICIAN FEE - SURGERY PF-REPAIR FIBULA NONUNION EACH 27726 "$2,621.00 " 960 "$1,834.70 " "$1,310.50 " "$2,096.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312531 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER DEFORMITY EACH 26590 "$3,912.00 " 960 "$2,738.40 " "$1,956.00 " "$3,129.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311889 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER TENDON EACH 26418 "$1,659.00 " 960 "$1,161.30 " $829.50 "$1,327.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311921 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER TENDON EACH 26432 "$1,446.00 " 960 "$1,012.20 " $723.00 "$1,156.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311939 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER TENDON EACH 26433 "$1,525.00 " 960 "$1,067.50 " $762.50 "$1,220.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311749 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER/HAND TENDON EACH 26350 "$1,993.00 " 960 "$1,395.10 " $996.50 "$1,594.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311764 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER/HAND TENDON EACH 26356 "$2,165.00 " 960 "$1,515.50 " "$1,082.50 " "$1,732.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311772 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER/HAND TENDON EACH 26357 "$2,444.00 " 960 "$1,710.80 " "$1,222.00 " "$1,955.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311798 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER/HAND TENDON EACH 26370 "$2,096.00 " 960 "$1,467.20 " "$1,048.00 " "$1,676.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311814 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER/HAND TENDON EACH 26373 "$2,368.00 " 960 "$1,657.60 " "$1,184.00 " "$1,894.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311905 PHYSICIAN FEE - SURGERY PF-REPAIR FINGER/HAND TENDON EACH 26426 "$1,385.00 " 960 $969.50 $692.50 "$1,108.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335300 PHYSICIAN FEE - SURGERY PF-REPAIR FISTULA W/COLOSTOMY EACH 45805 "$4,145.00 " 960 "$2,901.50 " "$2,072.50 " "$3,316.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335326 PHYSICIAN FEE - SURGERY PF-REPAIR FISTULA W/COLOSTOMY EACH 45825 "$4,335.00 " 960 "$3,034.50 " "$2,167.50 " "$3,468.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310246 PHYSICIAN FEE - SURGERY PF-REPAIR FOREARM TENDON/MUSC EACH 25274 "$1,821.00 " 960 "$1,274.70 " $910.50 "$1,456.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310196 PHYSICIAN FEE - SURGERY PF-REPAIR FOREARM TENDON/MUSC EACH 25260 "$1,740.00 " 960 "$1,218.00 " $870.00 "$1,392.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310204 PHYSICIAN FEE - SURGERY PF-REPAIR FOREARM TENDON/MUSC EACH 25263 "$1,750.00 " 960 "$1,225.00 " $875.00 "$1,400.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310212 PHYSICIAN FEE - SURGERY PF-REPAIR FOREARM TENDON/MUSC EACH 25265 "$2,080.00 " 960 "$1,456.00 " "$1,040.00 " "$1,664.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310220 PHYSICIAN FEE - SURGERY PF-REPAIR FOREARM TENDON/MUSC EACH 25270 "$1,360.00 " 960 $952.00 $680.00 "$1,088.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310238 PHYSICIAN FEE - SURGERY PF-REPAIR FOREARM TENDON/MUSC EACH 25272 "$1,549.00 " 960 "$1,084.30 " $774.50 "$1,239.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324700 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33770 "$5,945.00 " 960 "$4,161.50 " "$2,972.50 " "$4,756.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324718 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33771 "$6,120.00 " 960 "$4,284.00 " "$3,060.00 " "$4,896.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324726 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33774 "$5,053.00 " 960 "$3,537.10 " "$2,526.50 " "$4,042.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324734 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33775 "$5,204.00 " 960 "$3,642.80 " "$2,602.00 " "$4,163.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324742 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33776 "$5,505.00 " 960 "$3,853.50 " "$2,752.50 " "$4,404.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324759 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33777 "$5,312.00 " 960 "$3,718.40 " "$2,656.00 " "$4,249.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324767 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33778 "$6,607.00 " 960 "$4,624.90 " "$3,303.50 " "$5,285.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324775 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33779 "$6,530.00 " 960 "$4,571.00 " "$3,265.00 " "$5,224.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324783 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33780 "$6,652.00 " 960 "$4,656.40 " "$3,326.00 " "$5,321.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324791 PHYSICIAN FEE - SURGERY PF-REPAIR GREAT VESSELS DEFECT EACH 33781 "$6,496.00 " 960 "$4,547.20 " "$3,248.00 " "$5,196.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330863 PHYSICIAN FEE - SURGERY PF-REPAIR GUM EACH 41872 $813.00 960 $569.10 $406.50 $650.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317647 PHYSICIAN FEE - SURGERY PF-REPAIR HALLUX RIGIDUS EACH 28289 "$1,227.00 " 960 $858.90 $613.50 $981.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312515 PHYSICIAN FEE - SURGERY PF-REPAIR HAND DEFORMITY EACH 26580 "$4,209.00 " 960 "$2,946.30 " "$2,104.50 " "$3,367.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312333 PHYSICIAN FEE - SURGERY PF-REPAIR HAND JOINT EACH 26540 "$1,876.00 " 960 "$1,313.20 " $938.00 "$1,500.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312341 PHYSICIAN FEE - SURGERY PF-REPAIR HAND JOINT W/GRAFT EACH 26541 "$2,251.00 " 960 "$1,575.70 " "$1,125.50 " "$1,800.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312358 PHYSICIAN FEE - SURGERY PF-REPAIR HAND JOINT W/GRAFT EACH 26542 "$1,936.00 " 960 "$1,355.20 " $968.00 "$1,548.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350457 PHYSICIAN FEE - SURGERY PF-REPAIR HAND OR FOOT NERVE EACH 64834 "$2,022.00 " 960 "$1,415.40 " "$1,011.00 " "$1,617.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350465 PHYSICIAN FEE - SURGERY PF-REPAIR HAND OR FOOT NERVE EACH 64835 "$2,249.00 " 960 "$1,574.30 " "$1,124.50 " "$1,799.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350473 PHYSICIAN FEE - SURGERY PF-REPAIR HAND OR FOOT NERVE EACH 64836 "$2,249.00 " 960 "$1,574.30 " "$1,124.50 " "$1,799.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311848 PHYSICIAN FEE - SURGERY PF-REPAIR HAND TENDON EACH 26410 "$1,603.00 " 960 "$1,122.10 " $801.50 "$1,282.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324361 PHYSICIAN FEE - SURGERY PF-REPAIR HEART SEPTUM DEFECT EACH 33641 "$4,604.00 " 960 "$3,222.80 " "$2,302.00 " "$3,683.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324452 PHYSICIAN FEE - SURGERY PF-REPAIR HEART SEPTUM DEFECT EACH 33681 "$5,173.00 " 960 "$3,621.10 " "$2,586.50 " "$4,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324460 PHYSICIAN FEE - SURGERY PF-REPAIR HEART SEPTUM DEFECT EACH 33684 "$5,301.00 " 960 "$3,710.70 " "$2,650.50 " "$4,240.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324478 PHYSICIAN FEE - SURGERY PF-REPAIR HEART SEPTUM DEFECT EACH 33688 "$5,289.00 " 960 "$3,702.30 " "$2,644.50 " "$4,231.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324387 PHYSICIAN FEE - SURGERY PF-REPAIR HEART SEPTUM DEFECTS EACH 33647 "$5,100.00 " 960 "$3,570.00 " "$2,550.00 " "$4,080.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323934 PHYSICIAN FEE - SURGERY PF-REPAIR HEART VESSEL FISTULA EACH 33500 "$4,329.00 " 960 "$3,030.30 " "$2,164.50 " "$3,463.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323942 PHYSICIAN FEE - SURGERY PF-REPAIR HEART VESSEL FISTULA EACH 33501 "$3,092.00 " 960 "$2,164.40 " "$1,546.00 " "$2,473.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324593 PHYSICIAN FEE - SURGERY PF-REPAIR HEART-VEIN DEFECT EACH 33732 "$4,630.00 " 960 "$3,241.00 " "$2,315.00 " "$3,704.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324585 PHYSICIAN FEE - SURGERY PF-REPAIR HEART-VEIN DEFECT(S) EACH 33730 "$5,636.00 " 960 "$3,945.20 " "$2,818.00 " "$4,508.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309248 PHYSICIAN FEE - SURGERY PF-REPAIR HUMERUS WITH GRAFT EACH 24435 "$2,970.00 " 960 "$2,079.00 " "$1,485.00 " "$2,376.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337777 PHYSICIAN FEE - SURGERY PF-REPAIR ING HERNIA SLIDING EACH 49525 "$1,623.00 " 960 "$1,136.10 " $811.50 "$1,298.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351695 PHYSICIAN FEE - SURGERY PF-REPAIR IRIS & CILIARY BODY EACH 66680 "$1,332.00 " 960 $932.40 $666.00 "$1,065.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351703 PHYSICIAN FEE - SURGERY PF-REPAIR IRIS & CILIARY BODY EACH 66682 "$1,816.00 " 960 "$1,271.20 " $908.00 "$1,452.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348840 PHYSICIAN FEE - SURGERY PF-REPAIR LAMINECTOMY DEFECT EACH 63295 $992.00 960 $694.40 $496.00 $793.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323058 PHYSICIAN FEE - SURGERY PF-REPAIR LEAD PACE-DEFIB DUAL EACH 33220 "$1,046.00 " 960 $732.20 $523.00 $836.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323041 PHYSICIAN FEE - SURGERY PF-REPAIR LEAD PACE-DEFIB ONE EACH 33218 "$1,065.00 " 960 $745.50 $532.50 $852.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315914 PHYSICIAN FEE - SURGERY PF-REPAIR LEG FASCIA DEFECT EACH 27656 $916.00 960 $641.20 $458.00 $732.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330129 PHYSICIAN FEE - SURGERY PF-REPAIR LIP EACH 40652 $975.00 960 $682.50 $487.50 $780.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330111 PHYSICIAN FEE - SURGERY PF-REPAIR LIP EACH 40650 $861.00 960 $602.70 $430.50 $688.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330137 PHYSICIAN FEE - SURGERY PF-REPAIR LIP EACH 40654 "$1,145.00 " 960 $801.50 $572.50 $916.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336290 PHYSICIAN FEE - SURGERY PF-REPAIR LIVER WOUND EACH 47350 "$3,828.00 " 960 "$2,679.60 " "$1,914.00 " "$3,062.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336308 PHYSICIAN FEE - SURGERY PF-REPAIR LIVER WOUND EACH 47360 "$5,314.00 " 960 "$3,719.80 " "$2,657.00 " "$4,251.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336316 PHYSICIAN FEE - SURGERY PF-REPAIR LIVER WOUND EACH 47361 "$8,477.00 " 960 "$5,933.90 " "$4,238.50 " "$6,781.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336324 PHYSICIAN FEE - SURGERY PF-REPAIR LIVER WOUND EACH 47362 "$4,106.00 " 960 "$2,874.20 " "$2,053.00 " "$3,284.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316268 PHYSICIAN FEE - SURGERY PF-REPAIR LOWER LEG EPIPHYSES EACH 27734 "$1,816.00 " 960 "$1,271.20 " $908.00 "$1,452.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315963 PHYSICIAN FEE - SURGERY PF-REPAIR LOWER LEG TENDONS EACH 27675 "$1,336.00 " 960 $935.20 $668.00 "$1,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315971 PHYSICIAN FEE - SURGERY PF-REPAIR LOWER LEG TENDONS EACH 27676 "$1,657.00 " 960 "$1,159.90 " $828.50 "$1,325.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337785 PHYSICIAN FEE - SURGERY PF-REPAIR LUMBAR HERNIA EACH 49540 "$1,896.00 " 960 "$1,327.20 " $948.00 "$1,516.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322621 PHYSICIAN FEE - SURGERY PF-REPAIR LUNG HERNIA EACH 32800 "$2,638.00 " 960 "$1,846.60 " "$1,319.00 " "$2,110.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323488 PHYSICIAN FEE - SURGERY PF-REPAIR MAJ BLOOD VESSEL(S) EACH 33320 "$2,997.00 " 960 "$2,097.90 " "$1,498.50 " "$2,397.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323504 PHYSICIAN FEE - SURGERY PF-REPAIR MAJ BLOOD VESSEL(S) EACH 33322 "$3,911.00 " 960 "$2,737.70 " "$1,955.50 " "$3,128.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323496 PHYSICIAN FEE - SURGERY PF-REPAIR MAJOR VESSEL EACH 33321 "$3,291.00 " 960 "$2,303.70 " "$1,645.50 " "$2,632.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324304 PHYSICIAN FEE - SURGERY PF-REPAIR MODIFIED FONTAN EACH 33615 "$5,610.00 " 960 "$3,927.00 " "$2,805.00 " "$4,488.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330327 PHYSICIAN FEE - SURGERY PF-REPAIR MOUTH LACERATION EACH 40830 $381.00 960 $266.70 $190.50 $304.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330335 PHYSICIAN FEE - SURGERY PF-REPAIR MOUTH LACERATION EACH 40831 $526.00 960 $368.20 $263.00 $420.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320179 PHYSICIAN FEE - SURGERY PF-REPAIR MOUTH/NOSE FISTULA EACH 30600 "$1,009.00 " 960 $706.30 $504.50 $807.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312549 PHYSICIAN FEE - SURGERY PF-REPAIR MUSCLES OF HAND EACH 26591 "$1,295.00 " 960 $906.50 $647.50 "$1,036.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320138 PHYSICIAN FEE - SURGERY PF-REPAIR NASAL DEFECT EACH 30540 "$1,958.00 " 960 "$1,370.60 " $979.00 "$1,566.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320146 PHYSICIAN FEE - SURGERY PF-REPAIR NASAL DEFECT EACH 30545 "$2,658.00 " 960 "$1,860.60 " "$1,329.00 " "$2,126.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320195 PHYSICIAN FEE - SURGERY PF-REPAIR NASAL SEPTUM DEFECT EACH 30630 "$1,775.00 " 960 "$1,242.50 " $887.50 "$1,420.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320112 PHYSICIAN FEE - SURGERY PF-REPAIR NASAL STENOSIS EACH 30465 "$2,729.00 " 960 "$1,910.30 " "$1,364.50 " "$2,183.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350440 PHYSICIAN FEE - SURGERY PF-REPAIR NERVE ADD-ON EACH 64832 $908.00 960 $635.60 $454.00 $726.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350481 PHYSICIAN FEE - SURGERY PF-REPAIR NERVE ADD-ON EACH 64837 $999.00 960 $699.30 $499.50 $799.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350622 PHYSICIAN FEE - SURGERY PF-REPAIR NERVE/SHORTEN BONE EACH 64876 $540.00 960 $378.00 $270.00 $432.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310576 PHYSICIAN FEE - SURGERY PF-REPAIR NONUNION CARPAL BONE EACH 25431 "$2,175.00 " 960 "$1,522.50 " "$1,087.50 " "$1,740.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312374 PHYSICIAN FEE - SURGERY PF-REPAIR NONUNION HAND EACH 26546 "$2,793.00 " 960 "$1,955.10 " "$1,396.50 " "$2,234.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331085 PHYSICIAN FEE - SURGERY PF-REPAIR NOSE TO LIP FISTULA EACH 42260 "$1,806.00 " 960 "$1,264.20 " $903.00 "$1,444.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338080 PHYSICIAN FEE - SURGERY PF-REPAIR OF ABDOMINAL WALL EACH 49900 "$2,306.00 " 960 "$1,614.20 " "$1,153.00 " "$1,844.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315906 PHYSICIAN FEE - SURGERY PF-REPAIR OF ACHILLES TENDON EACH 27654 "$1,931.00 " 960 "$1,351.70 " $965.50 "$1,544.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335904 PHYSICIAN FEE - SURGERY PF-REPAIR OF ANAL SPHINCTER EACH 46750 "$1,704.00 " 960 "$1,192.80 " $852.00 "$1,363.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335912 PHYSICIAN FEE - SURGERY PF-REPAIR OF ANAL SPHINCTER EACH 46751 "$1,875.00 " 960 "$1,312.50 " $937.50 "$1,500.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335946 PHYSICIAN FEE - SURGERY PF-REPAIR OF ANAL SPHINCTER EACH 46760 "$2,938.00 " 960 "$2,056.60 " "$1,469.00 " "$2,350.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335953 PHYSICIAN FEE - SURGERY PF-REPAIR OF ANAL SPHINCTER EACH 46761 "$2,479.00 " 960 "$1,735.30 " "$1,239.50 " "$1,983.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335755 PHYSICIAN FEE - SURGERY PF-REPAIR OF ANAL STRICTURE EACH 46700 "$1,760.00 " 960 "$1,232.00 " $880.00 "$1,408.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335763 PHYSICIAN FEE - SURGERY PF-REPAIR OF ANAL STRICTURE EACH 46705 "$1,593.00 " 960 "$1,115.10 " $796.50 "$1,274.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316060 PHYSICIAN FEE - SURGERY PF-REPAIR OF ANKLE LIGAMENT EACH 27695 "$1,317.00 " 960 $921.90 $658.50 "$1,053.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316086 PHYSICIAN FEE - SURGERY PF-REPAIR OF ANKLE LIGAMENT EACH 27698 "$1,726.00 " 960 "$1,208.20 " $863.00 "$1,380.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316078 PHYSICIAN FEE - SURGERY PF-REPAIR OF ANKLE LIGAMENTS EACH 27696 "$1,471.00 " 960 "$1,029.70 " $735.50 "$1,176.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323710 PHYSICIAN FEE - SURGERY PF-REPAIR OF AORTIC VALVE EACH 33414 "$6,037.00 " 960 "$4,225.90 " "$3,018.50 " "$4,829.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323744 PHYSICIAN FEE - SURGERY PF-REPAIR OF AORTIC VALVE EACH 33417 "$4,685.00 " 960 "$3,279.50 " "$2,342.50 " "$3,748.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350549 PHYSICIAN FEE - SURGERY PF-REPAIR OF ARM NERVES EACH 64861 "$4,574.00 " 960 "$3,201.80 " "$2,287.00 " "$3,659.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308984 PHYSICIAN FEE - SURGERY PF-REPAIR OF ARM TENDON EACH 24320 "$2,153.00 " 960 "$1,507.10 " "$1,076.50 " "$1,722.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309024 PHYSICIAN FEE - SURGERY PF-REPAIR OF BICEPS TENDON EACH 24340 "$1,636.00 " 960 "$1,145.20 " $818.00 "$1,308.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340011 PHYSICIAN FEE - SURGERY PF-REPAIR OF BLADDER OPENING EACH 51880 "$1,250.00 " 960 $875.00 $625.00 "$1,000.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339997 PHYSICIAN FEE - SURGERY PF-REPAIR OF BLADDER WOUND EACH 51860 "$2,011.00 " 960 "$1,407.70 " "$1,005.50 " "$1,608.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340003 PHYSICIAN FEE - SURGERY PF-REPAIR OF BLADDER WOUND EACH 51865 "$2,397.00 " 960 "$1,677.90 " "$1,198.50 " "$1,917.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319049 PHYSICIAN FEE - SURGERY PF-REPAIR OF BODY CAST EACH 29720 $121.00 960 $84.70 $60.50 $96.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343270 PHYSICIAN FEE - SURGERY PF-REPAIR OF BOWEL BULGE EACH 57268 "$1,373.00 " 960 $961.10 $686.50 "$1,098.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334386 PHYSICIAN FEE - SURGERY PF-REPAIR OF BOWEL LESION EACH 44605 "$3,603.00 " 960 "$2,522.10 " "$1,801.50 " "$2,882.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343288 PHYSICIAN FEE - SURGERY PF-REPAIR OF BOWEL POUCH EACH 57270 "$2,217.00 " 960 "$1,551.90 " "$1,108.50 " "$1,773.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341498 PHYSICIAN FEE - SURGERY PF-REPAIR OF CIRCUMCISION EACH 54163 $582.00 960 $407.40 $291.00 $465.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335870 PHYSICIAN FEE - SURGERY PF-REPAIR OF CLOACAL ANOMALY EACH 46744 "$10,028.00 " 960 "$7,019.60 " "$5,014.00 " "$8,022.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335888 PHYSICIAN FEE - SURGERY PF-REPAIR OF CLOACAL ANOMALY EACH 46746 "$11,051.00 " 960 "$7,735.70 " "$5,525.50 " "$8,840.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335896 PHYSICIAN FEE - SURGERY PF-REPAIR OF CLOACAL ANOMALY EACH 46748 "$11,982.00 " 960 "$8,387.40 " "$5,991.00 " "$9,585.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329980 PHYSICIAN FEE - SURGERY PF-REPAIR OF DIAPHRAGM HERNIA EACH 39503 "$16,373.00 " 960 "$11,461.10 " "$8,186.50 " "$13,098.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329998 PHYSICIAN FEE - SURGERY PF-REPAIR OF DIAPHRAGM HERNIA EACH 39540 "$2,444.00 " 960 "$1,710.80 " "$1,222.00 " "$1,955.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330004 PHYSICIAN FEE - SURGERY PF-REPAIR OF DIAPHRAGM HERNIA EACH 39541 "$2,630.00 " 960 "$1,841.00 " "$1,315.00 " "$2,104.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350432 PHYSICIAN FEE - SURGERY PF-REPAIR OF DIGIT NERVE EACH 64831 "$1,891.00 " 960 "$1,323.70 " $945.50 "$1,512.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353931 PHYSICIAN FEE - SURGERY PF-REPAIR OF EARDRUM EACH 69610 $774.00 960 $541.80 $387.00 $619.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353949 PHYSICIAN FEE - SURGERY PF-REPAIR OF EARDRUM EACH 69620 "$1,319.00 " 960 $923.30 $659.50 "$1,055.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352909 PHYSICIAN FEE - SURGERY PF-REPAIR OF ECTROPION; SUTURE EACH 67914 $846.00 960 $592.20 $423.00 $676.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352941 PHYSICIAN FEE - SURGERY PF-REPAIR OF ENTROPION; SUTURE EACH 67921 $799.00 960 $559.30 $399.50 $639.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332521 PHYSICIAN FEE - SURGERY PF-REPAIR OF ESOPHAGUS EACH 43300 "$1,686.00 " 960 "$1,180.20 " $843.00 "$1,348.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332547 PHYSICIAN FEE - SURGERY PF-REPAIR OF ESOPHAGUS EACH 43310 "$4,170.00 " 960 "$2,919.00 " "$2,085.00 " "$3,336.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351083 PHYSICIAN FEE - SURGERY PF-REPAIR OF EYE SOCKET WOUND EACH 65290 "$1,252.00 " 960 $876.40 $626.00 "$1,001.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350564 PHYSICIAN FEE - SURGERY PF-REPAIR OF FACIAL NERVE EACH 64864 "$2,321.00 " 960 "$1,624.70 " "$1,160.50 " "$1,856.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350572 PHYSICIAN FEE - SURGERY PF-REPAIR OF FACIAL NERVE EACH 64865 "$2,900.00 " 960 "$2,030.00 " "$1,450.00 " "$2,320.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316250 PHYSICIAN FEE - SURGERY PF-REPAIR OF FIBULA EPIPHYSIS EACH 27732 "$1,254.00 " 960 $877.80 $627.00 "$1,003.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317852 PHYSICIAN FEE - SURGERY PF-REPAIR OF FOOT BONES EACH 28320 "$1,669.00 " 960 "$1,168.30 " $834.50 "$1,335.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317423 PHYSICIAN FEE - SURGERY PF-REPAIR OF FOOT TENDON EACH 28208 $855.00 960 $598.50 $427.50 $684.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317613 PHYSICIAN FEE - SURGERY PF-REPAIR OF HAMMERTOE EACH 28285 "$1,023.00 " 960 $716.10 $511.50 $818.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317621 PHYSICIAN FEE - SURGERY PF-REPAIR OF HAMMERTOE EACH 28286 $782.00 960 $547.40 $391.00 $625.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324411 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART CHAMBERS EACH 33670 "$5,542.00 " 960 "$3,879.40 " "$2,771.00 " "$4,433.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324205 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART DAMAGE EACH 33545 "$8,513.00 " 960 "$5,959.10 " "$4,256.50 " "$6,810.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324544 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART DEFECT EACH 33720 "$4,345.00 " 960 "$3,041.50 " "$2,172.50 " "$3,476.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324395 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART DEFECTS EACH 33660 "$4,930.00 " 960 "$3,451.00 " "$2,465.00 " "$3,944.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324403 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART DEFECTS EACH 33665 "$5,373.00 " 960 "$3,761.10 " "$2,686.50 " "$4,298.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324494 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART DEFECTS EACH 33692 "$5,494.00 " 960 "$3,845.80 " "$2,747.00 " "$4,395.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324502 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART DEFECTS EACH 33694 "$5,478.00 " 960 "$3,834.60 " "$2,739.00 " "$4,382.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324510 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART DEFECTS EACH 33697 "$5,773.00 " 960 "$4,041.10 " "$2,886.50 " "$4,618.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324528 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART DEFECTS EACH 33702 "$4,343.00 " 960 "$3,040.10 " "$2,171.50 " "$3,474.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324536 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART DEFECTS EACH 33710 "$5,759.00 " 960 "$4,031.30 " "$2,879.50 " "$4,607.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323447 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART WOUND EACH 33300 "$6,840.00 " 960 "$4,788.00 " "$3,420.00 " "$5,472.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323454 PHYSICIAN FEE - SURGERY PF-REPAIR OF HEART WOUND EACH 33305 "$11,475.00 " 960 "$8,032.50 " "$5,737.50 " "$9,180.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309230 PHYSICIAN FEE - SURGERY PF-REPAIR OF HUMERUS EACH 24430 "$2,902.00 " 960 "$2,031.40 " "$1,451.00 " "$2,321.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335862 PHYSICIAN FEE - SURGERY PF-REPAIR OF IMPERFORATED ANUS EACH 46742 "$7,093.00 " 960 "$4,965.10 " "$3,546.50 " "$5,674.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338650 PHYSICIAN FEE - SURGERY PF-REPAIR OF KIDNEY WOUND EACH 50500 "$3,658.00 " 960 "$2,560.60 " "$1,829.00 " "$2,926.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314701 PHYSICIAN FEE - SURGERY PF-REPAIR OF KNEE CARTILAGE EACH 27403 "$1,781.00 " 960 "$1,246.70 " $890.50 "$1,424.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314719 PHYSICIAN FEE - SURGERY PF-REPAIR OF KNEE LIGAMENT EACH 27405 "$1,863.00 " 960 "$1,304.10 " $931.50 "$1,490.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314727 PHYSICIAN FEE - SURGERY PF-REPAIR OF KNEE LIGAMENT EACH 27407 "$2,197.00 " 960 "$1,537.90 " "$1,098.50 " "$1,757.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314735 PHYSICIAN FEE - SURGERY PF-REPAIR OF KNEE LIGAMENTS EACH 27409 "$2,663.00 " 960 "$1,864.10 " "$1,331.50 " "$2,130.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314578 PHYSICIAN FEE - SURGERY PF-REPAIR OF KNEECAP TENDON EACH 27380 "$1,704.00 " 960 "$1,192.80 " $852.00 "$1,363.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316276 PHYSICIAN FEE - SURGERY PF-REPAIR OF LEG EPIPHYSES EACH 27740 "$1,956.00 " 960 "$1,369.20 " $978.00 "$1,564.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316284 PHYSICIAN FEE - SURGERY PF-REPAIR OF LEG EPIPHYSES EACH 27742 "$2,146.00 " 960 "$1,502.20 " "$1,073.00 " "$1,716.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350499 PHYSICIAN FEE - SURGERY PF-REPAIR OF LEG NERVE EACH 64840 "$2,649.00 " 960 "$1,854.30 " "$1,324.50 " "$2,119.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315922 PHYSICIAN FEE - SURGERY PF-REPAIR OF LEG TENDON EACH EACH 27658 $995.00 960 $696.50 $497.50 $796.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315930 PHYSICIAN FEE - SURGERY PF-REPAIR OF LEG TENDON EACH EACH 27659 "$1,271.00 " 960 $889.70 $635.50 "$1,016.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315948 PHYSICIAN FEE - SURGERY PF-REPAIR OF LEG TENDON EACH EACH 27664 $979.00 960 $685.30 $489.50 $783.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315955 PHYSICIAN FEE - SURGERY PF-REPAIR OF LEG TENDON EACH EACH 27665 "$1,148.00 " 960 $803.60 $574.00 $918.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350556 PHYSICIAN FEE - SURGERY PF-REPAIR OF LOW BACK NERVES EACH 64862 "$3,780.00 " 960 "$2,646.00 " "$1,890.00 " "$3,024.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316219 PHYSICIAN FEE - SURGERY PF-REPAIR OF LOWER LEG EACH 27725 "$3,348.00 " 960 "$2,343.60 " "$1,674.00 " "$2,678.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316235 PHYSICIAN FEE - SURGERY PF-REPAIR OF LOWER LEG EACH 27727 "$2,862.00 " 960 "$2,003.40 " "$1,431.00 " "$2,289.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334543 PHYSICIAN FEE - SURGERY PF-REPAIR OF MESENTERY EACH 44850 "$2,103.00 " 960 "$1,472.10 " "$1,051.50 " "$1,682.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317860 PHYSICIAN FEE - SURGERY PF-REPAIR OF METATARSALS EACH 28322 "$1,564.00 " 960 "$1,094.80 " $782.00 "$1,251.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323777 PHYSICIAN FEE - SURGERY PF-REPAIR OF MITRAL VALVE EACH 33425 "$7,630.00 " 960 "$5,341.00 " "$3,815.00 " "$6,104.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323785 PHYSICIAN FEE - SURGERY PF-REPAIR OF MITRAL VALVE EACH 33426 "$6,660.00 " 960 "$4,662.00 " "$3,330.00 " "$5,328.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323793 PHYSICIAN FEE - SURGERY PF-REPAIR OF MITRAL VALVE EACH 33427 "$6,795.00 " 960 "$4,756.50 " "$3,397.50 " "$5,436.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320120 PHYSICIAN FEE - SURGERY PF-REPAIR OF NASAL SEPTUM EACH 30520 "$1,787.00 " 960 "$1,250.90 " $893.50 "$1,429.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341928 PHYSICIAN FEE - SURGERY PF-REPAIR OF PENIS EACH 54440 "$3,389.00 " 960 "$2,372.30 " "$1,694.50 " "$2,711.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342918 PHYSICIAN FEE - SURGERY PF-REPAIR OF PERINEUM EACH 56810 $744.00 960 $520.80 $372.00 $595.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335268 PHYSICIAN FEE - SURGERY PF-REPAIR OF RECTOCELE EACH 45560 "$1,875.00 " 960 "$1,312.50 " $937.50 "$1,500.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335201 PHYSICIAN FEE - SURGERY PF-REPAIR OF RECTUM EACH 45500 "$1,268.00 " 960 $887.60 $634.00 "$1,014.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335219 PHYSICIAN FEE - SURGERY PF-REPAIR OF RECTUM EACH 45505 "$1,629.00 " 960 "$1,140.30 " $814.50 "$1,303.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329444 PHYSICIAN FEE - SURGERY PF-REPAIR OF RUPTURED SPLEEN EACH 38115 "$3,671.00 " 960 "$2,569.70 " "$1,835.50 " "$2,936.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309040 PHYSICIAN FEE - SURGERY PF-REPAIR OF RUPTURED TENDON EACH 24342 "$2,128.00 " 960 "$1,489.60 " "$1,064.00 " "$1,702.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344203 PHYSICIAN FEE - SURGERY PF-REPAIR OF RUPTURED UTERUS EACH 58520 "$2,185.00 " 960 "$1,529.50 " "$1,092.50 " "$1,748.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308042 PHYSICIAN FEE - SURGERY PF-REPAIR OF SHOULDER EACH 23420 "$2,680.00 " 960 "$1,876.00 " "$1,340.00 " "$2,144.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347479 PHYSICIAN FEE - SURGERY PF-REPAIR OF SKULL & BRAIN EACH 62145 "$4,279.00 " 960 "$2,995.30 " "$2,139.50 " "$3,423.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347438 PHYSICIAN FEE - SURGERY PF-REPAIR OF SKULL DEFECT EACH 62140 "$3,002.00 " 960 "$2,101.40 " "$1,501.00 " "$2,401.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347446 PHYSICIAN FEE - SURGERY PF-REPAIR OF SKULL DEFECT EACH 62141 "$3,394.00 " 960 "$2,375.80 " "$1,697.00 " "$2,715.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347495 PHYSICIAN FEE - SURGERY PF-REPAIR OF SKULL WITH GRAFT EACH 62147 "$4,212.00 " 960 "$2,948.40 " "$2,106.00 " "$3,369.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342348 PHYSICIAN FEE - SURGERY PF-REPAIR OF SPERM DUCT EACH 55400 "$1,333.00 " 960 $933.10 $666.50 "$1,066.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349079 PHYSICIAN FEE - SURGERY PF-REPAIR OF SPINAL HERNIATION EACH 63700 "$3,938.00 " 960 "$2,756.60 " "$1,969.00 " "$3,150.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349087 PHYSICIAN FEE - SURGERY PF-REPAIR OF SPINAL HERNIATION EACH 63702 "$4,307.00 " 960 "$3,014.90 " "$2,153.50 " "$3,445.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349095 PHYSICIAN FEE - SURGERY PF-REPAIR OF SPINAL HERNIATION EACH 63704 "$5,007.00 " 960 "$3,504.90 " "$2,503.50 " "$4,005.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349103 PHYSICIAN FEE - SURGERY PF-REPAIR OF SPINAL HERNIATION EACH 63706 "$5,568.00 " 960 "$3,897.60 " "$2,784.00 " "$4,454.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333347 PHYSICIAN FEE - SURGERY PF-REPAIR OF STOMACH LESION EACH 43840 "$3,849.00 " 960 "$2,694.30 " "$1,924.50 " "$3,079.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315047 PHYSICIAN FEE - SURGERY PF-REPAIR OF THIGH EACH 27470 "$3,252.00 " 960 "$2,276.40 " "$1,626.00 " "$2,601.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314594 PHYSICIAN FEE - SURGERY PF-REPAIR OF THIGH MUSCLE EACH 27385 "$1,656.00 " 960 "$1,159.20 " $828.00 "$1,324.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316185 PHYSICIAN FEE - SURGERY PF-REPAIR OF TIBIA EACH 27720 "$2,392.00 " 960 "$1,674.40 " "$1,196.00 " "$1,913.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316243 PHYSICIAN FEE - SURGERY PF-REPAIR OF TIBIA EPIPHYSIS EACH 27730 "$1,626.00 " 960 "$1,138.20 " $813.00 "$1,300.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318389 PHYSICIAN FEE - SURGERY PF-REPAIR OF TOE DISLOCATION EACH 28675 "$1,109.00 " 960 $776.30 $554.50 $887.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339278 PHYSICIAN FEE - SURGERY PF-REPAIR OF URETER EACH 50900 "$2,236.00 " 960 "$1,565.20 " "$1,118.00 " "$1,788.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339591 PHYSICIAN FEE - SURGERY PF-REPAIR OF URETER LESION EACH 51535 "$2,069.00 " 960 "$1,448.30 " "$1,034.50 " "$1,655.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340896 PHYSICIAN FEE - SURGERY PF-REPAIR OF URETHRA DEFECT EACH 53275 $703.00 960 $492.10 $351.50 $562.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341134 PHYSICIAN FEE - SURGERY PF-REPAIR OF URETHRA DEFECT EACH 53520 "$1,489.00 " 960 "$1,042.30 " $744.50 "$1,191.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341092 PHYSICIAN FEE - SURGERY PF-REPAIR OF URETHRA INJURY EACH 53502 "$1,296.00 " 960 $907.20 $648.00 "$1,036.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341100 PHYSICIAN FEE - SURGERY PF-REPAIR OF URETHRA INJURY EACH 53505 "$1,295.00 " 960 $906.50 $647.50 "$1,036.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341118 PHYSICIAN FEE - SURGERY PF-REPAIR OF URETHRA INJURY EACH 53510 "$1,681.00 " 960 "$1,176.70 " $840.50 "$1,344.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341126 PHYSICIAN FEE - SURGERY PF-REPAIR OF URETHRA INJURY EACH 53515 "$2,110.00 " 960 "$1,477.00 " "$1,055.00 " "$1,688.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343213 PHYSICIAN FEE - SURGERY PF-REPAIR OF URETHRAL LESION EACH 57230 "$1,144.00 " 960 $800.80 $572.00 $915.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345127 PHYSICIAN FEE - SURGERY PF-REPAIR OF UTERUS EACH 59350 $818.00 960 $572.60 $409.00 $654.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342892 PHYSICIAN FEE - SURGERY PF-REPAIR OF VAGINA EACH 56800 $689.00 960 $482.30 $344.50 $551.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343247 PHYSICIAN FEE - SURGERY PF-REPAIR OF VAGINA EACH 57260 "$2,124.00 " 960 "$1,486.80 " "$1,062.00 " "$1,699.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312457 PHYSICIAN FEE - SURGERY PF-REPAIR OF WEB FINGER EACH 26560 "$1,711.00 " 960 "$1,197.70 " $855.50 "$1,368.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312465 PHYSICIAN FEE - SURGERY PF-REPAIR OF WEB FINGER EACH 26561 "$2,668.00 " 960 "$1,867.60 " "$1,334.00 " "$2,134.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312473 PHYSICIAN FEE - SURGERY PF-REPAIR OF WEB FINGER EACH 26562 "$3,751.00 " 960 "$2,625.70 " "$1,875.50 " "$3,000.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321680 PHYSICIAN FEE - SURGERY PF-REPAIR OF WINDPIPE EACH 31750 "$3,561.00 " 960 "$2,492.70 " "$1,780.50 " "$2,848.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321698 PHYSICIAN FEE - SURGERY PF-REPAIR OF WINDPIPE EACH 31755 "$4,543.00 " 960 "$3,180.10 " "$2,271.50 " "$3,634.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321706 PHYSICIAN FEE - SURGERY PF-REPAIR OF WINDPIPE EACH 31760 "$3,856.00 " 960 "$2,699.20 " "$1,928.00 " "$3,084.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321813 PHYSICIAN FEE - SURGERY PF-REPAIR OF WINDPIPE DEFECT EACH 31825 "$1,309.00 " 960 $916.30 $654.50 "$1,047.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321789 PHYSICIAN FEE - SURGERY PF-REPAIR OF WINDPIPE INJURY EACH 31800 "$1,871.00 " 960 "$1,309.70 " $935.50 "$1,496.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321797 PHYSICIAN FEE - SURGERY PF-REPAIR OF WINDPIPE INJURY EACH 31805 "$2,292.00 " 960 "$1,604.40 " "$1,146.00 " "$1,833.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318264 PHYSICIAN FEE - SURGERY PF-REPAIR OPEN TALOTARS DISLOC EACH 28585 "$1,890.00 " 960 "$1,323.00 " $945.00 "$1,512.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318306 PHYSICIAN FEE - SURGERY PF-REPAIR OPEN TARSOMET DISLOC EACH 28615 "$2,236.00 " 960 "$1,565.20 " "$1,118.00 " "$1,788.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344591 PHYSICIAN FEE - SURGERY PF-REPAIR OVIDUCT EACH 58750 "$2,492.00 " 960 "$1,744.40 " "$1,246.00 " "$1,993.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330970 PHYSICIAN FEE - SURGERY PF-REPAIR PALATE EACH 42180 $502.00 960 $351.40 $251.00 $401.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330988 PHYSICIAN FEE - SURGERY PF-REPAIR PALATE EACH 42182 $694.00 960 $485.80 $347.00 $555.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331077 PHYSICIAN FEE - SURGERY PF-REPAIR PALATE EACH 42235 "$1,959.00 " 960 "$1,371.30 " $979.50 "$1,567.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330954 PHYSICIAN FEE - SURGERY PF-REPAIR PALATE PHARYNX/UVULA EACH 42145 "$1,846.00 " 960 "$1,292.20 " $923.00 "$1,476.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343551 PHYSICIAN FEE - SURGERY PF-REPAIR PARAVAG DEFECT LAP EACH 57423 "$2,529.00 " 960 "$1,770.30 " "$1,264.50 " "$2,023.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343320 PHYSICIAN FEE - SURGERY PF-REPAIR PARAVAG DEFECT OPEN EACH 57284 "$2,259.00 " 960 "$1,581.30 " "$1,129.50 " "$1,807.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343338 PHYSICIAN FEE - SURGERY PF-REPAIR PARAVAG DEFECT VAG EACH 57285 "$1,881.00 " 960 "$1,316.70 " $940.50 "$1,504.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341779 PHYSICIAN FEE - SURGERY PF-REPAIR PENIS EACH 54385 "$2,471.00 " 960 "$1,729.70 " "$1,235.50 " "$1,976.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341787 PHYSICIAN FEE - SURGERY PF-REPAIR PENIS AND BLADDER EACH 54390 "$3,289.00 " 960 "$2,302.30 " "$1,644.50 " "$2,631.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323926 PHYSICIAN FEE - SURGERY PF-REPAIR PROSTH VALVE CLOT EACH 33496 "$4,615.00 " 960 "$3,230.50 " "$2,307.50 " "$3,692.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324577 PHYSICIAN FEE - SURGERY PF-REPAIR PUL VENOUS STENOSIS EACH 33726 "$5,707.00 " 960 "$3,994.90 " "$2,853.50 " "$4,565.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325137 PHYSICIAN FEE - SURGERY PF-REPAIR PULMONARY ARTERY EACH 33917 "$4,092.00 " 960 "$2,864.40 " "$2,046.00 " "$3,273.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325145 PHYSICIAN FEE - SURGERY PF-REPAIR PULMONARY ATRESIA EACH 33920 "$5,081.00 " 960 "$3,556.70 " "$2,540.50 " "$4,064.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310527 PHYSICIAN FEE - SURGERY PF-REPAIR RADIUS & ULNA EACH 25415 "$2,667.00 " 960 "$1,866.90 " "$1,333.50 " "$2,133.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310501 PHYSICIAN FEE - SURGERY PF-REPAIR RADIUS OR ULNA EACH 25400 "$2,202.00 " 960 "$1,541.40 " "$1,101.00 " "$1,761.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352131 PHYSICIAN FEE - SURGERY PF-REPAIR RD INJECTION AIR/GAS EACH 67110 "$2,076.00 " 960 "$1,453.20 " "$1,038.00 " "$1,660.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335292 PHYSICIAN FEE - SURGERY PF-REPAIR RECT/BLADDER FISTULA EACH 45800 "$3,594.00 " 960 "$2,515.80 " "$1,797.00 " "$2,875.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335250 PHYSICIAN FEE - SURGERY PF-REPAIR RECTM/REMOVE SIGMOID EACH 45550 "$3,947.00 " 960 "$2,762.90 " "$1,973.50 " "$3,157.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343239 PHYSICIAN FEE - SURGERY PF-REPAIR RECTUM & VAGINA EACH 57250 "$1,677.00 " 960 "$1,173.90 " $838.50 "$1,341.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343429 PHYSICIAN FEE - SURGERY PF-REPAIR RECTUM-VAG FISTULA EACH 57305 "$2,684.00 " 960 "$1,878.80 " "$1,342.00 " "$2,147.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343411 PHYSICIAN FEE - SURGERY PF-REPAIR RECTUM-VAGFISTULA EACH 57300 "$1,666.00 " 960 "$1,166.20 " $833.00 "$1,332.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338676 PHYSICIAN FEE - SURGERY PF-REPAIR RENAL-ABD FISTULA EACH 50525 "$4,178.00 " 960 "$2,924.60 " "$2,089.00 " "$3,342.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338684 PHYSICIAN FEE - SURGERY PF-REPAIR RENAL-ABD FISTULA EACH 50526 "$4,477.00 " 960 "$3,133.90 " "$2,238.50 " "$3,581.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352156 PHYSICIAN FEE - SURGERY PF-REPAIR RETINAL DETACH CPLX EACH 67113 "$3,391.00 " 960 "$2,373.70 " "$1,695.50 " "$2,712.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308018 PHYSICIAN FEE - SURGERY PF-REPAIR ROTATOR CUFF ACUTE EACH 23410 "$2,253.00 " 960 "$1,577.10 " "$1,126.50 " "$1,802.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308026 PHYSICIAN FEE - SURGERY PF-REPAIR ROTATOR CUFF CHRONIC EACH 23412 "$2,344.00 " 960 "$1,640.80 " "$1,172.00 " "$1,875.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331291 PHYSICIAN FEE - SURGERY PF-REPAIR SALIVARY DUCT EACH 42500 $921.00 960 $644.70 $460.50 $736.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331309 PHYSICIAN FEE - SURGERY PF-REPAIR SALIVARY DUCT EACH 42505 "$1,230.00 " 960 $861.00 $615.00 $984.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350523 PHYSICIAN FEE - SURGERY PF-REPAIR SCIATIC NERVE EACH 64858 "$3,237.00 " 960 "$2,265.90 " "$1,618.50 " "$2,589.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324874 PHYSICIAN FEE - SURGERY PF-REPAIR SEPTAL DEFECT EACH 33813 "$3,481.00 " 960 "$2,436.70 " "$1,740.50 " "$2,784.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324882 PHYSICIAN FEE - SURGERY PF-REPAIR SEPTAL DEFECT EACH 33814 "$4,279.00 " 960 "$2,995.30 " "$2,139.50 " "$3,423.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324957 PHYSICIAN FEE - SURGERY PF-REPAIR SEPTAL DEFECT EACH 33852 "$3,930.00 " 960 "$2,751.00 " "$1,965.00 " "$3,144.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324965 PHYSICIAN FEE - SURGERY PF-REPAIR SEPTAL DEFECT EACH 33853 "$5,148.00 " 960 "$3,603.60 " "$2,574.00 " "$4,118.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308075 PHYSICIAN FEE - SURGERY PF-REPAIR SHOULDER CAPSULE EACH 23450 "$2,607.00 " 960 "$1,824.90 " "$1,303.50 " "$2,085.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308083 PHYSICIAN FEE - SURGERY PF-REPAIR SHOULDER CAPSULE EACH 23455 "$2,712.00 " 960 "$1,898.40 " "$1,356.00 " "$2,169.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308091 PHYSICIAN FEE - SURGERY PF-REPAIR SHOULDER CAPSULE EACH 23460 "$3,005.00 " 960 "$2,103.50 " "$1,502.50 " "$2,404.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308109 PHYSICIAN FEE - SURGERY PF-REPAIR SHOULDER CAPSULE EACH 23462 "$2,944.00 " 960 "$2,060.80 " "$1,472.00 " "$2,355.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308117 PHYSICIAN FEE - SURGERY PF-REPAIR SHOULDER CAPSULE EACH 23465 "$3,082.00 " 960 "$2,157.40 " "$1,541.00 " "$2,465.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308125 PHYSICIAN FEE - SURGERY PF-REPAIR SHOULDER CAPSULE EACH 23466 "$3,086.00 " 960 "$2,160.20 " "$1,543.00 " "$2,468.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324312 PHYSICIAN FEE - SURGERY PF-REPAIR SINGLE VENTRICLE EACH 33617 "$6,080.00 " 960 "$4,256.00 " "$3,040.00 " "$4,864.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324320 PHYSICIAN FEE - SURGERY PF-REPAIR SINGLE VENTRICLE EACH 33619 "$7,705.00 " 960 "$5,393.50 " "$3,852.50 " "$6,164.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347412 PHYSICIAN FEE - SURGERY PF-REPAIR SKULL CAVITY LESION EACH 62120 "$6,097.00 " 960 "$4,267.90 " "$3,048.50 " "$4,877.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349111 PHYSICIAN FEE - SURGERY PF-REPAIR SPINAL FLUID LEAKAGE EACH 63707 "$2,728.00 " 960 "$1,909.60 " "$1,364.00 " "$2,182.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349129 PHYSICIAN FEE - SURGERY PF-REPAIR SPINAL FLUID LEAKAGE EACH 63709 "$3,235.00 " 960 "$2,264.50 " "$1,617.50 " "$2,588.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306541 PHYSICIAN FEE - SURGERY PF-REPAIR STERN/NUSS W/O SCOPE EACH 21742 "$2,350.00 " 960 "$1,645.00 " "$1,175.00 " "$1,880.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306558 PHYSICIAN FEE - SURGERY PF-REPAIR STERNUM SEPARATION EACH 21750 "$1,897.00 " 960 "$1,327.90 " $948.50 "$1,517.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333446 PHYSICIAN FEE - SURGERY PF-REPAIR STOMACH OPENING EACH 43870 "$1,995.00 " 960 "$1,396.50 " $997.50 "$1,596.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354665 PHYSICIAN FEE - SURGERY PF-REPAIR TCAT MITRAL VALVE EACH 33418 "$4,988.00 " 960 "$3,491.60 " "$2,494.00 " "$3,990.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354673 PHYSICIAN FEE - SURGERY PF-REPAIR TCAT MITRAL VALVE EACH 33419 "$1,174.00 " 960 $821.80 $587.00 $939.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353378 PHYSICIAN FEE - SURGERY PF-REPAIR TEAR DUCTS EACH 68700 "$1,540.00 " 960 "$1,078.00 " $770.00 "$1,232.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342082 PHYSICIAN FEE - SURGERY PF-REPAIR TESTIS INJURY EACH 54670 "$1,089.00 " 960 $762.30 $544.50 $871.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331671 PHYSICIAN FEE - SURGERY PF-REPAIR THROAT ESOPHAGUS EACH 42953 "$2,511.00 " 960 "$1,757.70 " "$1,255.50 " "$2,008.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331655 PHYSICIAN FEE - SURGERY PF-REPAIR THROAT WOUND EACH 42900 $894.00 960 $625.80 $447.00 $715.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318348 PHYSICIAN FEE - SURGERY PF-REPAIR TOE DISLOCATION EACH 28645 "$1,298.00 " 960 $908.60 $649.00 "$1,038.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330681 PHYSICIAN FEE - SURGERY PF-REPAIR TONGUE LACERATION EACH 41250 $417.00 960 $291.90 $208.50 $333.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330699 PHYSICIAN FEE - SURGERY PF-REPAIR TONGUE LACERATION EACH 41251 $501.00 960 $350.70 $250.50 $400.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330707 PHYSICIAN FEE - SURGERY PF-REPAIR TONGUE LACERATION EACH 41252 $564.00 960 $394.80 $282.00 $451.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330871 PHYSICIAN FEE - SURGERY PF-REPAIR TOOTH SOCKET EACH 41874 $639.00 960 $447.30 $319.50 $511.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328248 PHYSICIAN FEE - SURGERY PF-REPAIR TUNNELED CV CATH EACH 36575 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328255 PHYSICIAN FEE - SURGERY PF-REPAIR TUNNELED CV CATH EACH 36576 $498.00 960 $348.60 $249.00 $398.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337959 PHYSICIAN FEE - SURGERY PF-REPAIR UMBILICAL LESION EACH 49600 "$2,084.00 " 960 "$1,458.80 " "$1,042.00 " "$1,667.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337967 PHYSICIAN FEE - SURGERY PF-REPAIR UMBILICAL LESION EACH 49605 "$13,998.00 " 960 "$9,798.60 " "$6,999.00 " "$11,198.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337975 PHYSICIAN FEE - SURGERY PF-REPAIR UMBILICAL LESION EACH 49606 "$3,229.00 " 960 "$2,260.30 " "$1,614.50 " "$2,583.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337983 PHYSICIAN FEE - SURGERY PF-REPAIR UMBILICAL LESION EACH 49610 "$1,969.00 " 960 "$1,378.30 " $984.50 "$1,575.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337991 PHYSICIAN FEE - SURGERY PF-REPAIR UMBILICAL LESION EACH 49611 "$1,731.00 " 960 "$1,211.70 " $865.50 "$1,384.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320161 PHYSICIAN FEE - SURGERY PF-REPAIR UPPER JAW FISTULA EACH 30580 "$1,210.00 " 960 $847.00 $605.00 $968.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343452 PHYSICIAN FEE - SURGERY PF-REPAIR URETHROVAGINAL LES EACH 57310 "$1,313.00 " 960 $919.10 $656.50 "$1,050.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343460 PHYSICIAN FEE - SURGERY PF-REPAIR URETHROVAGINAL LES EACH 57311 "$1,481.00 " 960 "$1,036.70 " $740.50 "$1,184.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341050 PHYSICIAN FEE - SURGERY PF-REPAIR URO SPHINCTER EACH 53449 "$1,628.00 " 960 "$1,139.60 " $814.00 "$1,302.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343494 PHYSICIAN FEE - SURGERY PF-REPAIR VAGINA EACH 57335 "$3,221.00 " 960 "$2,254.70 " "$1,610.50 " "$2,576.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325541 PHYSICIAN FEE - SURGERY PF-REPAIR VALVE FEMORAL VEIN EACH 34501 "$2,525.00 " 960 "$1,767.50 " "$1,262.50 " "$2,020.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324569 PHYSICIAN FEE - SURGERY PF-REPAIR VENOUS ANOMALY EACH 33724 "$4,313.00 " 960 "$3,019.10 " "$2,156.50 " "$3,450.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324858 PHYSICIAN FEE - SURGERY PF-REPAIR VESSEL DEFECT EACH 33802 "$3,046.00 " 960 "$2,132.20 " "$1,523.00 " "$2,436.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324866 PHYSICIAN FEE - SURGERY PF-REPAIR VESSEL DEFECT EACH 33803 "$3,230.00 " 960 "$2,261.00 " "$1,615.00 " "$2,584.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327349 PHYSICIAN FEE - SURGERY PF-REPAIR VESSEL GRAFT DEFECT EACH 35870 "$3,529.00 " 960 "$2,470.30 " "$1,764.50 " "$2,823.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317902 PHYSICIAN FEE - SURGERY PF-REPAIR WEBBED TOE(S) EACH 28345 $948.00 960 $663.60 $474.00 $758.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321326 PHYSICIAN FEE - SURGERY PF-REPAIR WINDPIPE OPENING EACH 31613 "$1,129.00 " 960 $790.30 $564.50 $903.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321334 PHYSICIAN FEE - SURGERY PF-REPAIR WINDPIPE OPENING EACH 31614 "$1,896.00 " 960 "$1,327.20 " $948.00 "$1,516.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310659 PHYSICIAN FEE - SURGERY PF-REPAIR WRIST JOINT(S) EACH 25447 "$2,278.00 " 960 "$1,594.60 " "$1,139.00 " "$1,822.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315898 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT ACHILLES TEND EACH 27652 "$1,801.00 " 960 "$1,260.70 " $900.50 "$1,440.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351604 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT EYE LESION EACH 66225 "$2,393.00 " 960 "$1,675.10 " "$1,196.50 " "$1,914.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313711 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT FEMUR HEAD/NK EACH 27170 "$3,226.00 " 960 "$2,258.20 " "$1,613.00 " "$2,580.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311897 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT FINGER TENDON EACH 26420 "$1,990.00 " 960 "$1,393.00 " $995.00 "$1,592.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311913 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT FINGER TENDON EACH 26428 "$2,144.00 " 960 "$1,500.80 " "$1,072.00 " "$1,715.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311947 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT FINGER TENDON EACH 26434 "$1,871.00 " 960 "$1,309.70 " $935.50 "$1,496.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311756 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT HAND TENDON EACH 26352 "$2,227.00 " 960 "$1,558.90 " "$1,113.50 " "$1,781.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311780 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT HAND TENDON EACH 26358 "$2,701.00 " 960 "$1,890.70 " "$1,350.50 " "$2,160.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311806 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT HAND TENDON EACH 26372 "$2,465.00 " 960 "$1,725.50 " "$1,232.50 " "$1,972.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311830 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT HAND TENDON EACH 26392 "$2,706.00 " 960 "$1,894.20 " "$1,353.00 " "$2,164.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311855 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT HAND TENDON EACH 26412 "$1,916.00 " 960 "$1,341.20 " $958.00 "$1,532.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314586 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT KNEECAP TENDON EACH 27381 "$2,249.00 " 960 "$1,574.30 " "$1,124.50 " "$1,799.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321722 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT OF BRONCHUS EACH 31770 "$3,729.00 " 960 "$2,610.30 " "$1,864.50 " "$2,983.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317431 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT OF FOOT TENDON EACH 28210 "$1,129.00 " 960 $790.30 $564.50 $903.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315054 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT OF THIGH EACH 27472 "$3,483.00 " 960 "$2,438.10 " "$1,741.50 " "$2,786.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316193 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT OF TIBIA EACH 27722 "$2,466.00 " 960 "$1,726.20 " "$1,233.00 " "$1,972.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316201 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT OF TIBIA EACH 27724 "$3,457.00 " 960 "$2,419.90 " "$1,728.50 " "$2,765.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310535 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT RADIUS & ULNA EACH 25420 "$3,214.00 " 960 "$2,249.80 " "$1,607.00 " "$2,571.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310550 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT RADIUS & ULNA EACH 25426 "$3,096.00 " 960 "$2,167.20 " "$1,548.00 " "$2,476.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310519 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT RADIUS OR ULNA EACH 25405 "$2,841.00 " 960 "$1,988.70 " "$1,420.50 " "$2,272.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310543 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT RADIUS OR ULNA EACH 25425 "$2,656.00 " 960 "$1,859.20 " "$1,328.00 " "$2,124.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314602 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT THIGH MUSCLE EACH 27386 "$2,345.00 " 960 "$1,641.50 " "$1,172.50 " "$1,876.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310584 PHYSICIAN FEE - SURGERY PF-REPAIR/GRAFT WRIST BONE EACH 25440 "$2,110.00 " 960 "$1,477.00 " "$1,055.00 " "$1,688.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310352 PHYSICIAN FEE - SURGERY PF-REPAIR/REVISE WRIST JOINT EACH 25320 "$2,704.00 " 960 "$1,892.80 " "$1,352.00 " "$2,163.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350507 PHYSICIAN FEE - SURGERY PF-REPAIR/TRANSPOSE NERVE EACH 64856 "$2,772.00 " 960 "$1,940.40 " "$1,386.00 " "$2,217.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345564 PHYSICIAN FEE - SURGERY PF-REPEAT THYROID SURGERY EACH 60260 "$2,997.00 " 960 "$2,097.90 " "$1,498.50 " "$2,397.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323546 PHYSICIAN FEE - SURGERY PF-REPLACE AORTIC VALVE OPEN EACH 33362 "$3,668.00 " 960 "$2,567.60 " "$1,834.00 " "$2,934.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323553 PHYSICIAN FEE - SURGERY PF-REPLACE AORTIC VALVE OPEN EACH 33363 "$3,810.00 " 960 "$2,667.00 " "$1,905.00 " "$3,048.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323561 PHYSICIAN FEE - SURGERY PF-REPLACE AORTIC VALVE OPEN EACH 33364 "$3,796.00 " 960 "$2,657.20 " "$1,898.00 " "$3,036.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323579 PHYSICIAN FEE - SURGERY PF-REPLACE AORTIC VALVE OPEN EACH 33365 "$3,963.00 " 960 "$2,774.10 " "$1,981.50 " "$3,170.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323538 PHYSICIAN FEE - SURGERY PF-REPLACE AORTIC VALVE PERQ EACH 33361 "$3,364.00 " 960 "$2,354.80 " "$1,682.00 " "$2,691.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323587 PHYSICIAN FEE - SURGERY PF-REPLACE AORTIC VALVE W/BYP EACH 33367 "$1,698.00 " 960 "$1,188.60 " $849.00 "$1,358.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323595 PHYSICIAN FEE - SURGERY PF-REPLACE AORTIC VALVE W/BYP EACH 33368 "$2,058.00 " 960 "$1,440.60 " "$1,029.00 " "$1,646.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323603 PHYSICIAN FEE - SURGERY PF-REPLACE AORTIC VALVE W/BYP EACH 33369 "$2,717.00 " 960 "$1,901.90 " "$1,358.50 " "$2,173.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347693 PHYSICIAN FEE - SURGERY PF-REPLACE BRAIN CAVITY SHUNT EACH 62258 "$3,327.00 " 960 "$2,328.90 " "$1,663.50 " "$2,661.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328271 PHYSICIAN FEE - SURGERY PF-REPLACE CVAD CATH EACH 36580 $173.00 960 $121.10 $86.50 $138.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337637 PHYSICIAN FEE - SURGERY PF-REPLACE DUOD/JEJ TUBE PERC EACH 49451 $230.00 960 $161.00 $115.00 $184.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309156 PHYSICIAN FEE - SURGERY PF-REPLACE ELBOW JOINT EACH 24363 "$3,978.00 " 960 "$2,784.60 " "$1,989.00 " "$3,182.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351984 PHYSICIAN FEE - SURGERY PF-REPLACE EYE FLUID EACH 67025 "$1,611.00 " 960 "$1,127.70 " $805.50 "$1,288.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328313 PHYSICIAN FEE - SURGERY PF-REPLACE PICC CATH EACH 36584 $152.00 960 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328321 PHYSICIAN FEE - SURGERY PF-REPLACE PICVAD CATH EACH 36585 $742.00 960 $519.40 $371.00 $593.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347461 PHYSICIAN FEE - SURGERY PF-REPLACE SKULL PLATE/FLAP EACH 62143 "$3,118.00 " 960 "$2,182.60 " "$1,559.00 " "$2,494.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301146 PHYSICIAN FEE - SURGERY PF-REPLACE TISSUE EXPANDER EACH 11970 "$1,523.00 " 960 "$1,066.10 " $761.50 "$1,218.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323843 PHYSICIAN FEE - SURGERY PF-REPLACE TRICUSPID VALVE EACH 33465 "$7,692.00 " 960 "$5,384.40 " "$3,846.00 " "$6,153.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328263 PHYSICIAN FEE - SURGERY PF-REPLACE TUNNELED CV CATH EACH 36578 $556.00 960 $389.20 $278.00 $444.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328289 PHYSICIAN FEE - SURGERY PF-REPLACE TUNNELED CV CATH EACH 36581 $481.00 960 $336.70 $240.50 $384.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328305 PHYSICIAN FEE - SURGERY PF-REPLACE TUNNELED CV CATH EACH 36583 $923.00 960 $646.10 $461.50 $738.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339245 PHYSICIAN FEE - SURGERY PF-REPLACE URETER BY BOWEL EACH 50840 "$3,260.00 " 960 "$2,282.00 " "$1,630.00 " "$2,608.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325376 PHYSICIAN FEE - SURGERY PF-REPLACE VAD INTRA W/BP EACH 33983 "$6,373.00 " 960 "$4,461.10 " "$3,186.50 " "$5,098.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325368 PHYSICIAN FEE - SURGERY PF-REPLACE VAD INTRA W/O BP EACH 33982 "$5,416.00 " 960 "$3,791.20 " "$2,708.00 " "$4,332.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325350 PHYSICIAN FEE - SURGERY PF-REPLACE VAD PUMP EXT EACH 33981 "$2,302.00 " 960 "$1,611.40 " "$1,151.00 " "$1,841.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347602 PHYSICIAN FEE - SURGERY PF-REPLACE/IRRIGATE CATHETER EACH 62194 "$1,461.00 " 960 "$1,022.70 " $730.50 "$1,168.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347651 PHYSICIAN FEE - SURGERY PF-REPLACE/IRRIGATE CATHETER EACH 62225 "$1,580.00 " 960 "$1,106.00 " $790.00 "$1,264.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347669 PHYSICIAN FEE - SURGERY PF-REPLACE/REVISE BRAIN SHUNT EACH 62230 "$2,503.00 " 960 "$1,752.10 " "$1,251.50 " "$2,002.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323652 PHYSICIAN FEE - SURGERY PF-REPLACEMENT OF AORTIC VALVE EACH 33405 "$6,345.00 " 960 "$4,441.50 " "$3,172.50 " "$5,076.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323660 PHYSICIAN FEE - SURGERY PF-REPLACEMENT OF AORTIC VALVE EACH 33406 "$8,097.00 " 960 "$5,667.90 " "$4,048.50 " "$6,477.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323678 PHYSICIAN FEE - SURGERY PF-REPLACEMENT OF AORTIC VALVE EACH 33410 "$7,108.00 " 960 "$4,975.60 " "$3,554.00 " "$5,686.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323686 PHYSICIAN FEE - SURGERY PF-REPLACEMENT OF AORTIC VALVE EACH 33411 "$9,368.00 " 960 "$6,557.60 " "$4,684.00 " "$7,494.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323694 PHYSICIAN FEE - SURGERY PF-REPLACEMENT OF AORTIC VALVE EACH 33412 "$8,736.00 " 960 "$6,115.20 " "$4,368.00 " "$6,988.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323702 PHYSICIAN FEE - SURGERY PF-REPLACEMENT OF AORTIC VALVE EACH 33413 "$8,945.00 " 960 "$6,261.50 " "$4,472.50 " "$7,156.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323801 PHYSICIAN FEE - SURGERY PF-REPLACEMENT OF MITRAL VALVE EACH 33430 "$7,825.00 " 960 "$5,477.50 " "$3,912.50 " "$6,260.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323892 PHYSICIAN FEE - SURGERY PF-REPLACEMENT PULMONARY VALVE EACH 33475 "$6,459.00 " 960 "$4,521.30 " "$3,229.50 " "$5,167.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304389 PHYSICIAN FEE - SURGERY PF-REPLANT FOREARM COMPLETE EACH 20805 "$8,971.00 " 960 "$6,279.70 " "$4,485.50 " "$7,176.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304371 PHYSICIAN FEE - SURGERY PF-REPLANTATION ARM COMPLETE EACH 20802 "$7,547.00 " 960 "$5,282.90 " "$3,773.50 " "$6,037.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304405 PHYSICIAN FEE - SURGERY PF-REPLANTATION DIGIT COMPLETE EACH 20816 "$5,651.00 " 960 "$3,955.70 " "$2,825.50 " "$4,520.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304413 PHYSICIAN FEE - SURGERY PF-REPLANTATION DIGIT COMPLETE EACH 20822 "$4,873.00 " 960 "$3,411.10 " "$2,436.50 " "$3,898.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304447 PHYSICIAN FEE - SURGERY PF-REPLANTATION FOOT COMPLETE EACH 20838 "$7,653.00 " 960 "$5,357.10 " "$3,826.50 " "$6,122.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304397 PHYSICIAN FEE - SURGERY PF-REPLANTATION HAND COMPLETE EACH 20808 "$10,835.00 " 960 "$7,584.50 " "$5,417.50 " "$8,668.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360217 PHYSICIAN FEE - SURGERY PF-REPLANTATION OF PENIS EACH 54438 "$3,539.00 " 960 "$2,477.30 " "$1,769.50 " "$2,831.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304421 PHYSICIAN FEE - SURGERY PF-REPLANTATION THUMB COMPLETE EACH 20824 "$5,661.00 " 960 "$3,962.70 " "$2,830.50 " "$4,528.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304439 PHYSICIAN FEE - SURGERY PF-REPLANTATION THUMB COMPLETE EACH 20827 "$5,004.00 " 960 "$3,502.80 " "$2,502.00 " "$4,003.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354640 PHYSICIAN FEE - SURGERY PF-REPOS PREV IMPLTBL SUBQ DFB EACH 33273 "$1,111.00 " 960 $777.70 $555.50 $888.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333206 PHYSICIAN FEE - SURGERY PF-REPOSITION GASTROSTOMY TUBE EACH 43761 $286.00 960 $200.20 $143.00 $228.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351810 PHYSICIAN FEE - SURGERY PF-REPOSITION INTRAOCULAR LENS EACH 66825 "$2,125.00 " 960 "$1,487.50 " "$1,062.50 " "$1,700.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323116 PHYSICIAN FEE - SURGERY PF-REPOSITION L VENTRIC LEAD EACH 33226 "$1,027.00 " 960 $718.90 $513.50 $821.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323017 PHYSICIAN FEE - SURGERY PF-REPOSITION PACING-DEFB LEAD EACH 33215 $854.00 960 $597.80 $427.00 $683.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325418 PHYSICIAN FEE - SURGERY PF-REPOSITION VAD DIFF SESSION EACH 33993 $457.00 960 $319.90 $228.50 $365.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328404 PHYSICIAN FEE - SURGERY PF-REPOSITION VENOUS CATHETER EACH 36597 $159.00 960 $111.30 $79.50 $127.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309057 PHYSICIAN FEE - SURGERY PF-REPR ELBOW LAT LIGMT W/TISS EACH 24343 "$1,961.00 " 960 "$1,372.70 " $980.50 "$1,568.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309073 PHYSICIAN FEE - SURGERY PF-REPR ELBW MED LIGMNT W/TISS EACH 24345 "$1,953.00 " 960 "$1,367.10 " $976.50 "$1,562.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335771 PHYSICIAN FEE - SURGERY PF-REPR OF ANAL FISTULA W/GLUE EACH 46706 $504.00 960 $352.80 $252.00 $403.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335805 PHYSICIAN FEE - SURGERY PF-REPR PER/VAG POUCH DBL PROC EACH 46712 "$6,273.00 " 960 "$4,391.10 " "$3,136.50 " "$5,018.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335797 PHYSICIAN FEE - SURGERY PF-REPR PER/VAG POUCH SGL PROC EACH 46710 "$3,132.00 " 960 "$2,192.40 " "$1,566.00 " "$2,505.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325186 PHYSICIAN FEE - SURGERY PF-REPR PUL ART UNIFOCAL W/CPB EACH 33926 "$6,790.00 " 960 "$4,753.00 " "$3,395.00 " "$5,432.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337827 PHYSICIAN FEE - SURGERY PF-REREPAIR FEM HERNIA BLOCKED EACH 49557 "$2,048.00 " 960 "$1,433.60 " "$1,024.00 " "$1,638.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337819 PHYSICIAN FEE - SURGERY PF-REREPAIR FEM HERNIA REDUCE EACH 49555 "$1,715.00 " 960 "$1,200.50 " $857.50 "$1,372.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337769 PHYSICIAN FEE - SURGERY PF-REREPAIR ING HERNIA BLOCKED EACH 49521 "$2,031.00 " 960 "$1,421.70 " "$1,015.50 " "$1,624.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337751 PHYSICIAN FEE - SURGERY PF-REREPAIR ING HERNIA REDUCE EACH 49520 "$1,796.00 " 960 "$1,257.20 " $898.00 "$1,436.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352396 PHYSICIAN FEE - SURGERY PF-REREVISE EYE MUSCLES ADD-ON EACH 67332 $520.00 960 $364.00 $260.00 $416.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307523 PHYSICIAN FEE - SURGERY PF-RESECT ABD TUM < 5 CM EACH 22904 "$2,932.00 " 960 "$2,052.40 " "$1,466.00 " "$2,345.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307531 PHYSICIAN FEE - SURGERY PF-RESECT ABD TUM > 5 CM EACH 22905 "$3,731.00 " 960 "$2,611.70 " "$1,865.50 " "$2,984.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322167 PHYSICIAN FEE - SURGERY PF-RESECT APICAL LUNG TUM/CHST EACH 32504 "$5,744.00 " 960 "$4,020.80 " "$2,872.00 " "$4,595.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322159 PHYSICIAN FEE - SURGERY PF-RESECT APICAL LUNG TUMOR EACH 32503 "$5,036.00 " 960 "$3,525.20 " "$2,518.00 " "$4,028.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308661 PHYSICIAN FEE - SURGERY PF-RESECT ARM/ELBOW TUM < 5 CM EACH 24077 "$2,863.00 " 960 "$2,004.10 " "$1,431.50 " "$2,290.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308679 PHYSICIAN FEE - SURGERY PF-RESECT ARM/ELBOW TUM > 5 CM EACH 24079 "$3,694.00 " 960 "$2,585.80 " "$1,847.00 " "$2,955.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306657 PHYSICIAN FEE - SURGERY PF-RESECT BACK TUM < 5 CM EACH 21935 "$2,861.00 " 960 "$2,002.70 " "$1,430.50 " "$2,288.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306665 PHYSICIAN FEE - SURGERY PF-RESECT BACK TUM 5+ CM EACH 21936 "$3,968.00 " 960 "$2,777.60 " "$1,984.00 " "$3,174.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307911 PHYSICIAN FEE - SURGERY PF-RESECT CLAVICLE TUMOR EACH 23200 "$4,141.00 " 960 "$2,898.70 " "$2,070.50 " "$3,312.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330038 PHYSICIAN FEE - SURGERY PF-RESECT DIAPHRAGM COMPLEX EACH 39561 "$3,516.00 " 960 "$2,461.20 " "$1,758.00 " "$2,812.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330020 PHYSICIAN FEE - SURGERY PF-RESECT DIAPHRAGM SIMPLE EACH 39560 "$2,234.00 " 960 "$1,563.80 " "$1,117.00 " "$1,787.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311707 PHYSICIAN FEE - SURGERY PF-RESECT DISTAL FINGER TUMOR EACH 26262 "$1,741.00 " 960 "$1,218.70 " $870.50 "$1,392.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308869 PHYSICIAN FEE - SURGERY PF-RESECT DISTAL HUMERUS TUMOR EACH 24150 "$4,252.00 " 960 "$2,976.40 " "$2,126.00 " "$3,401.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317886 PHYSICIAN FEE - SURGERY PF-RESECT ENLARGED TOE EACH 28341 "$1,271.00 " 960 $889.70 $635.50 "$1,016.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317878 PHYSICIAN FEE - SURGERY PF-RESECT ENLARGED TOE TISSUE EACH 28340 "$1,068.00 " 960 $747.60 $534.00 $854.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304769 PHYSICIAN FEE - SURGERY PF-RESECT FACE TUM + CM EACH 21016 "$2,753.00 " 960 "$1,927.10 " "$1,376.50 " "$2,202.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304751 PHYSICIAN FEE - SURGERY PF-RESECT FACE TUM < 2 CM EACH 21015 "$1,884.00 " 960 "$1,318.80 " $942.00 "$1,507.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314545 PHYSICIAN FEE - SURGERY PF-RESECT FEMUR/KNEE TUMOR EACH 27365 "$5,653.00 " 960 "$3,957.10 " "$2,826.50 " "$4,522.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315856 PHYSICIAN FEE - SURGERY PF-RESECT FIBULA TUMOR EACH 27646 "$4,222.00 " 960 "$2,955.40 " "$2,111.00 " "$3,377.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316953 PHYSICIAN FEE - SURGERY PF-RESECT FOOT/TOE TUMOR < 3 EACH 28046 "$1,853.00 " 960 "$1,297.10 " $926.50 "$1,482.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316961 PHYSICIAN FEE - SURGERY PF-RESECT FOOT/TOE TUMOR > 3 EACH 28047 "$2,802.00 " 960 "$1,961.40 " "$1,401.00 " "$2,241.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309859 PHYSICIAN FEE - SURGERY PF-RESECT FOREARM/WRIST TUM<3 EACH 25077 "$2,429.00 " 960 "$1,700.30 " "$1,214.50 " "$1,943.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309867 PHYSICIAN FEE - SURGERY PF-RESECT FOREARM/WRIST TUM3+ EACH 25078 "$3,245.00 " 960 "$2,271.50 " "$1,622.50 " "$2,596.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313380 PHYSICIAN FEE - SURGERY PF-RESECT HIP TUM INCL ACETABL EACH 27076 "$6,931.00 " 960 "$4,851.70 " "$3,465.50 " "$5,544.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313398 PHYSICIAN FEE - SURGERY PF-RESECT HIP TUM W/INNOM BONE EACH 27077 "$7,734.00 " 960 "$5,413.80 " "$3,867.00 " "$6,187.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313372 PHYSICIAN FEE - SURGERY PF-RESECT HIP TUMOR EACH 27075 "$5,732.00 " 960 "$4,012.40 " "$2,866.00 " "$4,585.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313240 PHYSICIAN FEE - SURGERY PF-RESECT HIP/PELV TUM < 5 CM EACH 27049 "$3,925.00 " 960 "$2,747.50 " "$1,962.50 " "$3,140.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313299 PHYSICIAN FEE - SURGERY PF-RESECT HIP/PELV TUM > 5 CM EACH 27059 "$5,032.00 " 960 "$3,522.40 " "$2,516.00 " "$4,025.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319940 PHYSICIAN FEE - SURGERY PF-RESECT INFERIOR TURBINATE EACH 30140 $478.00 960 $334.60 $239.00 $382.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315690 PHYSICIAN FEE - SURGERY PF-RESECT LEG/ANKLE TUM < 5 CM EACH 27615 "$2,813.00 " 960 "$1,969.10 " "$1,406.50 " "$2,250.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315708 PHYSICIAN FEE - SURGERY PF-RESECT LEG/ANKLE TUM 5+ CM EACH 27616 "$3,496.00 " 960 "$2,447.20 " "$1,748.00 " "$2,796.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317357 PHYSICIAN FEE - SURGERY PF-RESECT METATARSAL TUMOR EACH 28173 "$1,896.00 " 960 "$1,327.20 " $948.00 "$1,516.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346653 PHYSICIAN FEE - SURGERY PF-RESECT NASOPHARYNX SKULL EACH 61586 "$7,329.00 " 960 "$5,130.30 " "$3,664.50 " "$5,863.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306384 PHYSICIAN FEE - SURGERY PF-RESECT NECK TUM < 5 CM EACH 21557 "$2,658.00 " 960 "$1,860.60 " "$1,329.00 " "$2,126.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306392 PHYSICIAN FEE - SURGERY PF-RESECT NECK TUM 5+ CM EACH 21558 "$3,721.00 " 960 "$2,604.70 " "$1,860.50 " "$2,976.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344732 PHYSICIAN FEE - SURGERY PF-RESECT OVARIAN MALIGNANCY EACH 58950 "$3,141.00 " 960 "$2,198.70 " "$1,570.50 " "$2,512.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344740 PHYSICIAN FEE - SURGERY PF-RESECT OVARIAN MALIGNANCY EACH 58951 "$3,943.00 " 960 "$2,760.10 " "$1,971.50 " "$3,154.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344757 PHYSICIAN FEE - SURGERY PF-RESECT OVARIAN MALIGNANCY EACH 58952 "$4,503.00 " 960 "$3,152.10 " "$2,251.50 " "$3,602.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317365 PHYSICIAN FEE - SURGERY PF-RESECT PHALANX OF TOE TUMOR EACH 28175 "$1,228.00 " 960 $859.60 $614.00 $982.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311699 PHYSICIAN FEE - SURGERY PF-RESECT PROX FINGER TUMOR EACH 26260 "$2,197.00 " 960 "$1,537.90 " "$1,098.50 " "$1,757.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307937 PHYSICIAN FEE - SURGERY PF-RESECT PROX HUMERUS TUMOR EACH 23220 "$5,319.00 " 960 "$3,723.30 " "$2,659.50 " "$4,255.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308877 PHYSICIAN FEE - SURGERY PF-RESECT RADIUS TUMOR EACH 24152 "$3,699.00 " 960 "$2,589.30 " "$1,849.50 " "$2,959.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310097 PHYSICIAN FEE - SURGERY PF-RESECT RADIUS/ULNAR TUMOR EACH 25170 "$4,041.00 " 960 "$2,828.70 " "$2,020.50 " "$3,232.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344807 PHYSICIAN FEE - SURGERY PF-RESECT RECUR GYN MAL W/LYM EACH 58958 "$4,536.00 " 960 "$3,175.20 " "$2,268.00 " "$3,628.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307929 PHYSICIAN FEE - SURGERY PF-RESECT SCAPULA TUMOR EACH 23210 "$4,864.00 " 960 "$3,404.80 " "$2,432.00 " "$3,891.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307671 PHYSICIAN FEE - SURGERY PF-RESECT SHOULDER TUM < 5 CM EACH 23077 "$3,173.00 " 960 "$2,221.10 " "$1,586.50 " "$2,538.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307689 PHYSICIAN FEE - SURGERY PF-RESECT SHOULDER TUM > 5 CM EACH 23078 "$3,175.00 " 960 "$2,222.50 " "$1,587.50 " "$2,540.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315864 PHYSICIAN FEE - SURGERY PF-RESECT TALUS/CALCANEUS TUM EACH 27647 "$2,598.00 " 960 "$1,818.60 " "$1,299.00 " "$2,078.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317340 PHYSICIAN FEE - SURGERY PF-RESECT TARSAL TUMOR EACH 28171 "$3,050.00 " 960 "$2,135.00 " "$1,525.00 " "$2,440.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314354 PHYSICIAN FEE - SURGERY PF-RESECT THIGH/KNEE TUM < 5 EACH 27329 "$2,900.00 " 960 "$2,030.00 " "$1,450.00 " "$2,320.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314537 PHYSICIAN FEE - SURGERY PF-RESECT THIGH/KNEE TUM 5+ CM EACH 27364 "$4,344.00 " 960 "$3,040.80 " "$2,172.00 " "$3,475.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315849 PHYSICIAN FEE - SURGERY PF-RESECT TIBIA TUMOR EACH 27645 "$4,864.00 " 960 "$3,404.80 " "$2,432.00 " "$3,891.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346737 PHYSICIAN FEE - SURGERY PF-RESECT/EXCISE CRANIAL LES EACH 61600 "$5,844.00 " 960 "$4,090.80 " "$2,922.00 " "$4,675.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346745 PHYSICIAN FEE - SURGERY PF-RESECT/EXCISE CRANIAL LES EACH 61601 "$7,127.00 " 960 "$4,988.90 " "$3,563.50 " "$5,701.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346752 PHYSICIAN FEE - SURGERY PF-RESECT/EXCISE CRANIAL LES EACH 61605 "$5,835.00 " 960 "$4,084.50 " "$2,917.50 " "$4,668.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346760 PHYSICIAN FEE - SURGERY PF-RESECT/EXCISE CRANIAL LES EACH 61606 "$8,453.00 " 960 "$5,917.10 " "$4,226.50 " "$6,762.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346778 PHYSICIAN FEE - SURGERY PF-RESECT/EXCISE CRANIAL LES EACH 61607 "$9,051.00 " 960 "$6,335.70 " "$4,525.50 " "$7,240.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346786 PHYSICIAN FEE - SURGERY PF-RESECT/EXCISE CRANIAL LES EACH 61608 "$9,768.00 " 960 "$6,837.60 " "$4,884.00 " "$7,814.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346836 PHYSICIAN FEE - SURGERY PF-RESECT/EXCISE LESION SKULL EACH 61615 "$8,319.00 " 960 "$5,823.30 " "$4,159.50 " "$6,655.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346844 PHYSICIAN FEE - SURGERY PF-RESECT/EXCISE LESION SKULL EACH 61616 "$9,812.00 " 960 "$6,868.40 " "$4,906.00 " "$7,849.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306251 PHYSICIAN FEE - SURGERY PF-RESET DISLOCATED JAW EACH 21480 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306269 PHYSICIAN FEE - SURGERY PF-RESET DISLOCATED JAW EACH 21485 "$1,999.00 " 960 "$1,399.30 " $999.50 "$1,599.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324213 PHYSICIAN FEE - SURGERY PF-RESTORE/REMODEL VENTRICLE EACH 33548 "$8,185.00 " 960 "$5,729.50 " "$4,092.50 " "$6,548.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347503 PHYSICIAN FEE - SURGERY PF-RETR BONE FLAP TO FIX SKULL EACH 62148 $381.00 960 $266.70 $190.50 $304.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344823 PHYSICIAN FEE - SURGERY PF-RETRIEVAL OF OOCYTE EACH 58970 $536.00 960 $375.20 $268.00 $428.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329048 PHYSICIAN FEE - SURGERY PF-REV OPN/PRQ TIB/PERO STENT EACH 37234 $774.00 960 $541.80 $387.00 $619.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333479 PHYSICIAN FEE - SURGERY PF-REV/REMOVE ELECTRD ANTRUM EACH 43882 "$3,949.00 " 960 "$2,764.30 " "$1,974.50 " "$3,159.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347313 PHYSICIAN FEE - SURGERY PF-REV/REMOVE NEUROELECTRODE EACH 61880 "$1,735.00 " 960 "$1,214.50 " $867.50 "$1,388.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349707 PHYSICIAN FEE - SURGERY PF-REV/REMOVE NEUROELECTRODE EACH 64585 $385.00 960 $269.50 $192.50 $308.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361041 PHYSICIAN FEE - SURGERY PF-REV/RPLCT HPGLSL NST ARY PG EACH 64583 "$2,326.00 " 960 "$1,628.20 " "$1,163.00 " "$1,860.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329394 PHYSICIAN FEE - SURGERY PF-REVASCULARIZATION PENIS EACH 37788 "$3,341.00 " 960 "$2,338.70 " "$1,670.50 " "$2,672.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308158 PHYSICIAN FEE - SURGERY PF-REVIS RECONST SHOULDER JT EACH 23473 "$4,412.00 " 960 "$3,088.40 " "$2,206.00 " "$3,529.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308166 PHYSICIAN FEE - SURGERY PF-REVIS RECONST SHOULDER JT EACH 23474 "$4,768.00 " 960 "$3,337.60 " "$2,384.00 " "$3,814.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322738 PHYSICIAN FEE - SURGERY PF-REVISE & REPAIR CHEST WALL EACH 32905 "$3,745.00 " 960 "$2,621.50 " "$1,872.50 " "$2,996.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322746 PHYSICIAN FEE - SURGERY PF-REVISE & REPAIR CHEST WALL EACH 32906 "$4,628.00 " 960 "$3,239.60 " "$2,314.00 " "$3,702.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337520 PHYSICIAN FEE - SURGERY PF-REVISE ABDOMEN-VENOUS SHUNT EACH 49426 "$1,899.00 " 960 "$1,329.30 " $949.50 "$1,519.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316052 PHYSICIAN FEE - SURGERY PF-REVISE ADDL LEG TENDON EACH 27692 $279.00 960 $195.30 $139.50 $223.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349988 PHYSICIAN FEE - SURGERY PF-REVISE ARM/LEG NERVE EACH 64708 "$1,372.00 " 960 $960.40 $686.00 "$1,097.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339625 PHYSICIAN FEE - SURGERY PF-REVISE BLADDER & URETER(S) EACH 51565 "$3,410.00 " 960 "$2,387.00 " "$1,705.00 " "$2,728.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303886 PHYSICIAN FEE - SURGERY PF-REVISE BREAST RECONSTRUCT EACH 19380 "$2,191.00 " 960 "$1,533.70 " "$1,095.50 " "$1,752.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307440 PHYSICIAN FEE - SURGERY PF-REVISE CERV ARTIFIC DISC EACH 22861 "$6,992.00 " 960 "$4,894.40 " "$3,496.00 " "$5,593.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347040 PHYSICIAN FEE - SURGERY PF-REVISE CIRCULATION TO HEAD EACH 61705 "$7,862.00 " 960 "$5,503.40 " "$3,931.00 " "$6,289.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347057 PHYSICIAN FEE - SURGERY PF-REVISE CIRCULATION TO HEAD EACH 61708 "$7,694.00 " 960 "$5,385.80 " "$3,847.00 " "$6,155.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347065 PHYSICIAN FEE - SURGERY PF-REVISE CIRCULATION TO HEAD EACH 61710 "$6,488.00 " 960 "$4,541.60 " "$3,244.00 " "$5,190.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351240 PHYSICIAN FEE - SURGERY PF-REVISE CORNEA WITH IMPLANT EACH 65770 "$3,595.00 " 960 "$2,516.50 " "$1,797.50 " "$2,876.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332596 PHYSICIAN FEE - SURGERY PF-REVISE ESOPHAGUS & STOMACH EACH 43325 "$3,857.00 " 960 "$2,699.90 " "$1,928.50 " "$3,085.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353683 PHYSICIAN FEE - SURGERY PF-REVISE EXTERNAL EAR EACH 69300 "$1,259.00 " 960 $881.30 $629.50 "$1,007.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306830 PHYSICIAN FEE - SURGERY PF-REVISE EXTRA SPINE SEGMENT EACH 22216 "$1,041.00 " 960 $728.70 $520.50 $832.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306871 PHYSICIAN FEE - SURGERY PF-REVISE EXTRA SPINE SEGMENT EACH 22226 "$1,025.00 " 960 $717.50 $512.50 $820.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352321 PHYSICIAN FEE - SURGERY PF-REVISE EYE MUSCLE EACH 67311 "$1,165.00 " 960 $815.50 $582.50 $932.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352347 PHYSICIAN FEE - SURGERY PF-REVISE EYE MUSCLE EACH 67314 "$1,165.00 " 960 $815.50 $582.50 $932.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352420 PHYSICIAN FEE - SURGERY PF-REVISE EYE MUSCLE ADD-ON EACH 67340 $746.00 960 $522.20 $373.00 $596.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352404 PHYSICIAN FEE - SURGERY PF-REVISE EYE MUSCLE W/SUTURE EACH 67334 $391.00 960 $273.70 $195.50 $312.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352362 PHYSICIAN FEE - SURGERY PF-REVISE EYE MUSCLE(S) EACH 67318 "$1,761.00 " 960 "$1,232.70 " $880.50 "$1,408.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351588 PHYSICIAN FEE - SURGERY PF-REVISE EYE SHUNT EACH 66185 "$2,174.00 " 960 "$1,521.80 " "$1,087.00 " "$1,739.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352610 PHYSICIAN FEE - SURGERY PF-REVISE EYE SOCKET IMPLANT EACH 67560 "$2,840.00 " 960 "$1,988.00 " "$1,420.00 " "$2,272.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305634 PHYSICIAN FEE - SURGERY PF-REVISE EYE SOCKETS EACH 21260 "$3,680.00 " 960 "$2,576.00 " "$1,840.00 " "$2,944.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305642 PHYSICIAN FEE - SURGERY PF-REVISE EYE SOCKETS EACH 21261 "$6,544.00 " 960 "$4,580.80 " "$3,272.00 " "$5,235.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305659 PHYSICIAN FEE - SURGERY PF-REVISE EYE SOCKETS EACH 21263 "$6,047.00 " 960 "$4,232.90 " "$3,023.50 " "$4,837.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305667 PHYSICIAN FEE - SURGERY PF-REVISE EYE SOCKETS EACH 21267 "$4,299.00 " 960 "$3,009.30 " "$2,149.50 " "$3,439.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305675 PHYSICIAN FEE - SURGERY PF-REVISE EYE SOCKETS EACH 21268 "$4,591.00 " 960 "$3,213.70 " "$2,295.50 " "$3,672.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350804 PHYSICIAN FEE - SURGERY PF-REVISE EYE WITH IMPLANT EACH 65093 "$1,883.00 " 960 "$1,318.10 " $941.50 "$1,506.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352727 PHYSICIAN FEE - SURGERY PF-REVISE EYELASHES EACH 67825 $312.00 960 $218.40 $156.00 $249.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352735 PHYSICIAN FEE - SURGERY PF-REVISE EYELASHES EACH 67830 $352.00 960 $246.40 $176.00 $281.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353204 PHYSICIAN FEE - SURGERY PF-REVISE EYELID LINING EACH 68330 "$1,176.00 " 960 $823.20 $588.00 $940.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353238 PHYSICIAN FEE - SURGERY PF-REVISE EYELID LINING EACH 68360 "$1,049.00 " 960 $734.30 $524.50 $839.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353246 PHYSICIAN FEE - SURGERY PF-REVISE EYELID LINING EACH 68362 "$1,673.00 " 960 "$1,171.10 " $836.50 "$1,338.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312317 PHYSICIAN FEE - SURGERY PF-REVISE FINGER JOINT EACH 26535 "$1,200.00 " 960 $840.00 $600.00 $960.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311541 PHYSICIAN FEE - SURGERY PF-REVISE FINGER JOINT EACH EACH 26135 "$1,519.00 " 960 "$1,063.30 " $759.50 "$1,215.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311558 PHYSICIAN FEE - SURGERY PF-REVISE FINGER JOINT EACH EACH 26140 "$1,395.00 " 960 $976.50 $697.50 "$1,116.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349962 PHYSICIAN FEE - SURGERY PF-REVISE FINGER/TOE NERVE EACH 64702 "$1,397.00 " 960 $977.90 $698.50 "$1,117.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333487 PHYSICIAN FEE - SURGERY PF-REVISE GASTRIC PORT OPEN EACH 43886 "$1,031.00 " 960 $721.70 $515.50 $824.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327398 PHYSICIAN FEE - SURGERY PF-REVISE GRAFT W/NONAUTO GRFT EACH 35883 "$3,369.00 " 960 "$2,358.30 " "$1,684.50 " "$2,695.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327372 PHYSICIAN FEE - SURGERY PF-REVISE GRAFT W/VEIN EACH 35879 "$2,591.00 " 960 "$1,813.70 " "$1,295.50 " "$2,072.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327380 PHYSICIAN FEE - SURGERY PF-REVISE GRAFT W/VEIN EACH 35881 "$2,892.00 " 960 "$2,024.40 " "$1,446.00 " "$2,313.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327406 PHYSICIAN FEE - SURGERY PF-REVISE GRAFT W/VEIN EACH 35884 "$3,507.00 " 960 "$2,454.90 " "$1,753.50 " "$2,805.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311822 PHYSICIAN FEE - SURGERY PF-REVISE HAND/FINGER TENDON EACH 26390 "$2,378.00 " 960 "$1,664.60 " "$1,189.00 " "$1,902.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349970 PHYSICIAN FEE - SURGERY PF-REVISE HAND/FOOT NERVE EACH 64704 $863.00 960 $604.10 $431.50 $690.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313760 PHYSICIAN FEE - SURGERY PF-REVISE HEAD/NECK OF FEMUR EACH 27179 "$2,695.00 " 960 "$1,886.50 " "$1,347.50 " "$2,156.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342405 PHYSICIAN FEE - SURGERY PF-REVISE HERNIA & SPERM VEINS EACH 55540 "$1,570.00 " 960 "$1,099.00 " $785.00 "$1,256.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313604 PHYSICIAN FEE - SURGERY PF-REVISE HIP JT REPLACEMENT EACH 27134 "$5,246.00 " 960 "$3,672.20 " "$2,623.00 " "$4,196.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313612 PHYSICIAN FEE - SURGERY PF-REVISE HIP JT REPLACEMENT EACH 27137 "$4,035.00 " 960 "$2,824.50 " "$2,017.50 " "$3,228.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313620 PHYSICIAN FEE - SURGERY PF-REVISE HIP JT REPLACEMENT EACH 27138 "$4,192.00 " 960 "$2,934.40 " "$2,096.00 " "$3,353.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338221 PHYSICIAN FEE - SURGERY PF-REVISE KIDNEY BLOOD VESSELS EACH 50100 "$3,068.00 " 960 "$2,147.60 " "$1,534.00 " "$2,454.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314875 PHYSICIAN FEE - SURGERY PF-REVISE KNEECAP EACH 27437 "$1,825.00 " 960 "$1,277.50 " $912.50 "$1,460.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314883 PHYSICIAN FEE - SURGERY PF-REVISE KNEECAP WITH IMPLANT EACH 27438 "$2,317.00 " 960 "$1,621.90 " "$1,158.50 " "$1,853.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312291 PHYSICIAN FEE - SURGERY PF-REVISE KNUCKLE JOINT EACH 26530 "$1,488.00 " 960 "$1,041.60 " $744.00 "$1,190.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312309 PHYSICIAN FEE - SURGERY PF-REVISE KNUCKLE WITH IMPLANT EACH 26531 "$1,731.00 " 960 "$1,211.70 " $865.50 "$1,384.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329295 PHYSICIAN FEE - SURGERY PF-REVISE LEG VEIN EACH 37700 $681.00 960 $476.70 $340.50 $544.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350010 PHYSICIAN FEE - SURGERY PF-REVISE LOW BACK NERVE(S) EACH 64714 "$2,132.00 " 960 "$1,492.40 " "$1,066.00 " "$1,705.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316045 PHYSICIAN FEE - SURGERY PF-REVISE LOWER LEG TENDON EACH 27691 "$2,015.00 " 960 "$1,410.50 " "$1,007.50 " "$1,612.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316037 PHYSICIAN FEE - SURGERY PF-REVISE LOWER LEG TENDON EACH 27690 "$1,716.00 " 960 "$1,201.20 " $858.00 "$1,372.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316011 PHYSICIAN FEE - SURGERY PF-REVISE LOWER LEG TENDONS EACH 27686 "$1,441.00 " 960 "$1,008.70 " $720.50 "$1,152.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307457 PHYSICIAN FEE - SURGERY PF-REVISE LUMBAR ARTIF DISC EACH 22862 "$6,973.00 " 960 "$4,881.10 " "$3,486.50 " "$5,578.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324890 PHYSICIAN FEE - SURGERY PF-REVISE MAJOR VESSEL EACH 33820 "$2,714.00 " 960 "$1,899.80 " "$1,357.00 " "$2,171.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324908 PHYSICIAN FEE - SURGERY PF-REVISE MAJOR VESSEL EACH 33822 "$2,863.00 " 960 "$2,004.10 " "$1,431.50 " "$2,290.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324916 PHYSICIAN FEE - SURGERY PF-REVISE MAJOR VESSEL EACH 33824 "$3,314.00 " 960 "$2,319.80 " "$1,657.00 " "$2,651.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354012 PHYSICIAN FEE - SURGERY PF-REVISE MIDDLE EAR & MASTOID EACH 69641 "$2,768.00 " 960 "$1,937.60 " "$1,384.00 " "$2,214.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354020 PHYSICIAN FEE - SURGERY PF-REVISE MIDDLE EAR & MASTOID EACH 69642 "$3,558.00 " 960 "$2,490.60 " "$1,779.00 " "$2,846.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354038 PHYSICIAN FEE - SURGERY PF-REVISE MIDDLE EAR & MASTOID EACH 69643 "$3,251.00 " 960 "$2,275.70 " "$1,625.50 " "$2,600.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354046 PHYSICIAN FEE - SURGERY PF-REVISE MIDDLE EAR & MASTOID EACH 69644 "$3,975.00 " 960 "$2,782.50 " "$1,987.50 " "$3,180.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354053 PHYSICIAN FEE - SURGERY PF-REVISE MIDDLE EAR & MASTOID EACH 69645 "$3,900.00 " 960 "$2,730.00 " "$1,950.00 " "$3,120.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354061 PHYSICIAN FEE - SURGERY PF-REVISE MIDDLE EAR & MASTOID EACH 69646 "$4,161.00 " 960 "$2,912.70 " "$2,080.50 " "$3,328.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354087 PHYSICIAN FEE - SURGERY PF-REVISE MIDDLE EAR BONE EACH 69660 "$2,463.00 " 960 "$1,724.10 " "$1,231.50 " "$1,970.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354095 PHYSICIAN FEE - SURGERY PF-REVISE MIDDLE EAR BONE EACH 69661 "$3,209.00 " 960 "$2,246.30 " "$1,604.50 " "$2,567.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354103 PHYSICIAN FEE - SURGERY PF-REVISE MIDDLE EAR BONE EACH 69662 "$3,094.00 " 960 "$2,165.80 " "$1,547.00 " "$2,475.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350879 PHYSICIAN FEE - SURGERY PF-REVISE OCULAR IMPLANT EACH 65125 $753.00 960 $527.10 $376.50 $602.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350911 PHYSICIAN FEE - SURGERY PF-REVISE OCULAR IMPLANT EACH 65150 "$1,791.00 " 960 "$1,253.70 " $895.50 "$1,432.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344609 PHYSICIAN FEE - SURGERY PF-REVISE OVARIAN TUBE(S) EACH 58752 "$2,486.00 " 960 "$1,740.20 " "$1,243.00 " "$1,988.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310337 PHYSICIAN FEE - SURGERY PF-REVISE PALSY HAND TENDON(S) EACH 25315 "$2,127.00 " 960 "$1,488.90 " "$1,063.50 " "$1,701.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310345 PHYSICIAN FEE - SURGERY PF-REVISE PALSY HAND TENDON(S) EACH 25316 "$2,528.00 " 960 "$1,769.60 " "$1,264.00 " "$2,022.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341688 PHYSICIAN FEE - SURGERY PF-REVISE PENIS/URETHRA EACH 54328 "$2,484.00 " 960 "$1,738.80 " "$1,242.00 " "$1,987.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341696 PHYSICIAN FEE - SURGERY PF-REVISE PENIS/URETHRA EACH 54332 "$2,678.00 " 960 "$1,874.60 " "$1,339.00 " "$2,142.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341704 PHYSICIAN FEE - SURGERY PF-REVISE PENIS/URETHRA EACH 54336 "$3,149.00 " 960 "$2,204.30 " "$1,574.50 " "$2,519.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323082 PHYSICIAN FEE - SURGERY PF-REVISE POCKET FOR DEFIB EACH 33223 "$1,123.00 " 960 $786.10 $561.50 $898.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323074 PHYSICIAN FEE - SURGERY PF-REVISE POCKET PACEMAKER EACH 33222 $938.00 960 $656.60 $469.00 $750.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343577 PHYSICIAN FEE - SURGERY PF-REVISE PROSTH VAG GRAFT LAP EACH 57426 "$2,370.00 " 960 "$1,659.00 " "$1,185.00 " "$1,896.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310428 PHYSICIAN FEE - SURGERY PF-REVISE RADIUS & ULNA EACH 25365 "$2,530.00 " 960 "$1,771.00 " "$1,265.00 " "$2,024.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310444 PHYSICIAN FEE - SURGERY PF-REVISE RADIUS & ULNA EACH 25375 "$2,629.00 " 960 "$1,840.30 " "$1,314.50 " "$2,103.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310436 PHYSICIAN FEE - SURGERY PF-REVISE RADIUS OR ULNA EACH 25370 "$2,786.00 " 960 "$1,950.20 " "$1,393.00 " "$2,228.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309180 PHYSICIAN FEE - SURGERY PF-REVISE RECONST ELBOW JOINT EACH 24370 "$4,212.00 " 960 "$2,948.40 " "$2,106.00 " "$3,369.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309198 PHYSICIAN FEE - SURGERY PF-REVISE RECONST ELBOW JOINT EACH 24371 "$4,852.00 " 960 "$3,396.40 " "$2,426.00 " "$3,881.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342389 PHYSICIAN FEE - SURGERY PF-REVISE SPERMATIC CORD VEINS EACH 55530 $941.00 960 $658.70 $470.50 $752.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342397 PHYSICIAN FEE - SURGERY PF-REVISE SPERMATIC CORD VEINS EACH 55535 "$1,147.00 " 960 $802.90 $573.50 $917.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348618 PHYSICIAN FEE - SURGERY PF-REVISE SPINAL CORD VESSELS EACH 63250 "$8,964.00 " 960 "$6,274.80 " "$4,482.00 " "$7,171.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348626 PHYSICIAN FEE - SURGERY PF-REVISE SPINAL CORD VESSELS EACH 63251 "$9,158.00 " 960 "$6,410.60 " "$4,579.00 " "$7,326.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348634 PHYSICIAN FEE - SURGERY PF-REVISE SPINAL CORD VESSELS EACH 63252 "$9,157.00 " 960 "$6,409.90 " "$4,578.50 " "$7,325.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349046 PHYSICIAN FEE - SURGERY PF-REVISE SPINE ELTRD PLATE EACH 63664 "$2,587.00 " 960 "$1,810.90 " "$1,293.50 " "$2,069.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349038 PHYSICIAN FEE - SURGERY PF-REVISE SPINE ELTRD PRQ ARAY EACH 63663 "$1,219.00 " 960 $853.30 $609.50 $975.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333420 PHYSICIAN FEE - SURGERY PF-REVISE STOMACH-BOWEL FUSION EACH 43860 "$4,627.00 " 960 "$3,238.90 " "$2,313.50 " "$3,701.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333438 PHYSICIAN FEE - SURGERY PF-REVISE STOMACH-BOWEL FUSION EACH 43865 "$4,864.00 " 960 "$3,404.80 " "$2,432.00 " "$3,891.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314693 PHYSICIAN FEE - SURGERY PF-REVISE THIGH MUSCLES/TENDNS EACH 27400 "$1,920.00 " 960 "$1,344.00 " $960.00 "$1,536.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312135 PHYSICIAN FEE - SURGERY PF-REVISE THUMB TENDON EACH 26490 "$2,267.00 " 960 "$1,586.90 " "$1,133.50 " "$1,813.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312168 PHYSICIAN FEE - SURGERY PF-REVISE THUMB TENDON EACH 26496 "$2,458.00 " 960 "$1,720.60 " "$1,229.00 " "$1,966.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352354 PHYSICIAN FEE - SURGERY PF-REVISE TWO EYE MUSCLES EACH 67316 "$1,822.00 " 960 "$1,275.40 " $911.00 "$1,457.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350036 PHYSICIAN FEE - SURGERY PF-REVISE ULNAR NERVE AT ELBOW EACH 64718 "$1,653.00 " 960 "$1,157.10 " $826.50 "$1,322.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350044 PHYSICIAN FEE - SURGERY PF-REVISE ULNAR NERVE AT WRIST EACH 64719 "$1,116.00 " 960 $781.20 $558.00 $892.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339088 PHYSICIAN FEE - SURGERY PF-REVISE URETER EACH 50727 "$1,369.00 " 960 $958.30 $684.50 "$1,095.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339096 PHYSICIAN FEE - SURGERY PF-REVISE URETER EACH 50728 "$1,861.00 " 960 "$1,302.70 " $930.50 "$1,488.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340904 PHYSICIAN FEE - SURGERY PF-REVISE URETHRA STAGE 1 EACH 53400 "$2,125.00 " 960 "$1,487.50 " "$1,062.50 " "$1,700.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340912 PHYSICIAN FEE - SURGERY PF-REVISE URETHRA STAGE 2 EACH 53405 "$2,316.00 " 960 "$1,621.20 " "$1,158.00 " "$1,852.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339237 PHYSICIAN FEE - SURGERY PF-REVISE URINE FLOW EACH 50830 "$4,764.00 " 960 "$3,334.80 " "$2,382.00 " "$3,811.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343403 PHYSICIAN FEE - SURGERY PF-REVISE VAG GRAFT OPEN ABD EACH 57296 "$2,623.00 " 960 "$1,836.10 " "$1,311.50 " "$2,098.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343395 PHYSICIAN FEE - SURGERY PF-REVISE VAG GRAFT VIA VAGINA EACH 57295 "$1,359.00 " 960 $951.30 $679.50 "$1,087.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323736 PHYSICIAN FEE - SURGERY PF-REVISE VENTRICLE MUSCLE EACH 33416 "$5,653.00 " 960 "$3,957.10 " "$2,826.50 " "$4,522.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321821 PHYSICIAN FEE - SURGERY PF-REVISE WINDPIPE SCAR EACH 31830 $984.00 960 $688.80 $492.00 $787.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310360 PHYSICIAN FEE - SURGERY PF-REVISE WRIST JOINT EACH 25332 "$2,316.00 " 960 "$1,621.20 " "$1,158.00 " "$1,852.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310261 PHYSICIAN FEE - SURGERY PF-REVISE WRIST/FOREARM TENDON EACH 25280 "$1,555.00 " 960 "$1,088.50 " $777.50 "$1,244.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353212 PHYSICIAN FEE - SURGERY PF-REVISE/GRAFT EYELID LINING EACH 68335 "$1,652.00 " 960 "$1,156.40 " $826.00 "$1,321.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353170 PHYSICIAN FEE - SURGERY PF-REVISE/GRAFT EYELID LINING EACH 68325 "$1,676.00 " 960 "$1,173.20 " $838.00 "$1,340.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353196 PHYSICIAN FEE - SURGERY PF-REVISE/GRAFT EYELID LINING EACH 68328 "$1,798.00 " 960 "$1,258.60 " $899.00 "$1,438.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312325 PHYSICIAN FEE - SURGERY PF-REVISE/IMPLANT FINGER JOINT EACH 26536 "$2,001.00 " 960 "$1,400.70 " "$1,000.50 " "$1,600.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347347 PHYSICIAN FEE - SURGERY PF-REVISE/REMOVE NEURORECEIVER EACH 61888 "$1,182.00 " 960 $827.40 $591.00 $945.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349061 PHYSICIAN FEE - SURGERY PF-REVISE/REMOVE NEURORECEIVER EACH 63688 $838.00 960 $586.60 $419.00 $670.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343346 PHYSICIAN FEE - SURGERY PF-REVISE/REMOVE SLING REPAIR EACH 57287 "$1,999.00 " 960 "$1,399.30 " $999.50 "$1,599.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315104 PHYSICIAN FEE - SURGERY PF-REVISE/REPLACE KNEE JOINT EACH 27486 "$3,864.00 " 960 "$2,704.80 " "$1,932.00 " "$3,091.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315112 PHYSICIAN FEE - SURGERY PF-REVISE/REPLACE KNEE JOINT EACH 27487 "$4,825.00 " 960 "$3,377.50 " "$2,412.50 " "$3,860.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349723 PHYSICIAN FEE - SURGERY PF-REVISE/RMV PN/GASTR STIMUL EACH 64595 $618.00 960 $432.60 $309.00 $494.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333396 PHYSICIAN FEE - SURGERY PF-REVISION GASTROPLASTY EACH 43848 "$5,501.00 " 960 "$3,850.70 " "$2,750.50 " "$4,400.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338692 PHYSICIAN FEE - SURGERY PF-REVISION HORSESHOE KIDNEY EACH 50540 "$3,039.00 " 960 "$2,127.30 " "$1,519.50 " "$2,431.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316003 PHYSICIAN FEE - SURGERY PF-REVISION LOWER LEG TENDON EACH 27685 "$1,254.00 " 960 $877.80 $627.00 "$1,003.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309677 PHYSICIAN FEE - SURGERY PF-REVISION OF AMPUTATION EACH 24935 "$3,349.00 " 960 "$2,344.30 " "$1,674.50 " "$2,679.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316094 PHYSICIAN FEE - SURGERY PF-REVISION OF ANKLE JOINT EACH 27700 "$1,637.00 " 960 "$1,145.90 " $818.50 "$1,309.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355134 PHYSICIAN FEE - SURGERY PF-REVISION OF AQUEOUS SHUNT EACH 66184 "$2,024.00 " 960 "$1,416.80 " "$1,012.00 " "$1,619.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309008 PHYSICIAN FEE - SURGERY PF-REVISION OF ARM MUSCLES EACH 24331 "$2,168.00 " 960 "$1,517.60 " "$1,084.00 " "$1,734.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308992 PHYSICIAN FEE - SURGERY PF-REVISION OF ARM MUSCLES EACH 24330 "$1,984.00 " 960 "$1,388.80 " $992.00 "$1,587.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350002 PHYSICIAN FEE - SURGERY PF-REVISION OF ARM NERVE(S) EACH 64713 "$2,241.00 " 960 "$1,568.70 " "$1,120.50 " "$1,792.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308976 PHYSICIAN FEE - SURGERY PF-REVISION OF ARM TENDON EACH 24310 "$1,306.00 " 960 $914.20 $653.00 "$1,044.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317811 PHYSICIAN FEE - SURGERY PF-REVISION OF BIG TOE EACH 28310 $968.00 960 $677.60 $484.00 $774.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340060 PHYSICIAN FEE - SURGERY PF-REVISION OF BLADDER & BOWEL EACH 51960 "$3,666.00 " 960 "$2,566.20 " "$1,833.00 " "$2,932.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340623 PHYSICIAN FEE - SURGERY PF-REVISION OF BLADDER NECK EACH 52500 "$1,313.00 " 960 $919.10 $656.50 "$1,050.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339948 PHYSICIAN FEE - SURGERY PF-REVISION OF BLADDER/URETHRA EACH 51800 "$2,751.00 " 960 "$1,925.70 " "$1,375.50 " "$2,200.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316029 PHYSICIAN FEE - SURGERY PF-REVISION OF CALF TENDON EACH 27687 "$1,226.00 " 960 $858.20 $613.00 $980.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343791 PHYSICIAN FEE - SURGERY PF-REVISION OF CERVIX EACH 57700 $963.00 960 $674.10 $481.50 $770.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343809 PHYSICIAN FEE - SURGERY PF-REVISION OF CERVIX EACH 57720 $906.00 960 $634.20 $453.00 $724.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345101 PHYSICIAN FEE - SURGERY PF-REVISION OF CERVIX EACH 59320 $440.00 960 $308.00 $220.00 $352.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345119 PHYSICIAN FEE - SURGERY PF-REVISION OF CERVIX EACH 59325 $702.00 960 $491.40 $351.00 $561.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328669 PHYSICIAN FEE - SURGERY PF-REVISION OF CIRCULATION EACH 37140 "$6,593.00 " 960 "$4,615.10 " "$3,296.50 " "$5,274.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328677 PHYSICIAN FEE - SURGERY PF-REVISION OF CIRCULATION EACH 37145 "$6,116.00 " 960 "$4,281.20 " "$3,058.00 " "$4,892.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328685 PHYSICIAN FEE - SURGERY PF-REVISION OF CIRCULATION EACH 37160 "$6,281.00 " 960 "$4,396.70 " "$3,140.50 " "$5,024.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328693 PHYSICIAN FEE - SURGERY PF-REVISION OF CIRCULATION EACH 37180 "$6,038.00 " 960 "$4,226.60 " "$3,019.00 " "$4,830.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308174 PHYSICIAN FEE - SURGERY PF-REVISION OF COLLAR BONE EACH 23480 "$2,263.00 " 960 "$1,584.10 " "$1,131.50 " "$1,810.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308182 PHYSICIAN FEE - SURGERY PF-REVISION OF COLLAR BONE EACH 23485 "$2,627.00 " 960 "$1,838.90 " "$1,313.50 " "$2,101.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334089 PHYSICIAN FEE - SURGERY PF-REVISION OF COLOSTOMY EACH 44345 "$2,916.00 " 960 "$2,041.20 " "$1,458.00 " "$2,332.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334071 PHYSICIAN FEE - SURGERY PF-REVISION OF COLOSTOMY EACH 44340 "$1,750.00 " 960 "$1,225.00 " $875.00 "$1,400.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334097 PHYSICIAN FEE - SURGERY PF-REVISION OF COLOSTOMY EACH 44346 "$3,289.00 " 960 "$2,302.30 " "$1,644.50 " "$2,631.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358989 PHYSICIAN FEE - SURGERY PF-REVISION OF CORNEA EACH 65765 $500.00 960 $350.00 $250.00 $400.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350028 PHYSICIAN FEE - SURGERY PF-REVISION OF CRANIAL NERVE EACH 64716 "$1,385.00 " 960 $969.50 $692.50 "$1,108.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330012 PHYSICIAN FEE - SURGERY PF-REVISION OF DIAPHRAGM EACH 39545 "$2,508.00 " 960 "$1,755.60 " "$1,254.00 " "$2,006.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309255 PHYSICIAN FEE - SURGERY PF-REVISION OF ELBOW JOINT EACH 24470 "$1,855.00 " 960 "$1,298.50 " $927.50 "$1,484.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320583 PHYSICIAN FEE - SURGERY PF-REVISION OF ETHMOID SINUS EACH 31254 $652.00 960 $456.40 $326.00 $521.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352784 PHYSICIAN FEE - SURGERY PF-REVISION OF EYELID EACH 67880 $943.00 960 $660.10 $471.50 $754.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353030 PHYSICIAN FEE - SURGERY PF-REVISION OF EYELID > 1/4 EACH 67966 "$1,674.00 " 960 "$1,171.80 " $837.00 "$1,339.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353022 PHYSICIAN FEE - SURGERY PF-REVISION OF EYELID TO 1/4 EACH 67961 "$1,162.00 " 960 $813.40 $581.00 $929.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313786 PHYSICIAN FEE - SURGERY PF-REVISION OF FEMUR EPIPHYSIS EACH 27185 "$1,984.00 " 960 "$1,388.80 " $992.00 "$1,587.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312192 PHYSICIAN FEE - SURGERY PF-REVISION OF FINGER EACH 26499 "$2,359.00 " 960 "$1,651.30 " "$1,179.50 " "$1,887.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317530 PHYSICIAN FEE - SURGERY PF-REVISION OF FOOT FASCIA EACH 28250 "$1,107.00 " 960 $774.90 $553.50 $885.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323900 PHYSICIAN FEE - SURGERY PF-REVISION OF HEART CHAMBER EACH 33476 "$4,277.00 " 960 "$2,993.90 " "$2,138.50 " "$3,421.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323918 PHYSICIAN FEE - SURGERY PF-REVISION OF HEART CHAMBER EACH 33478 "$4,416.00 " 960 "$3,091.20 " "$2,208.00 " "$3,532.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324601 PHYSICIAN FEE - SURGERY PF-REVISION OF HEART CHAMBER EACH 33735 "$3,639.00 " 960 "$2,547.30 " "$1,819.50 " "$2,911.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324619 PHYSICIAN FEE - SURGERY PF-REVISION OF HEART CHAMBER EACH 33736 "$3,949.00 " 960 "$2,764.30 " "$1,974.50 " "$3,159.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324627 PHYSICIAN FEE - SURGERY PF-REVISION OF HEART CHAMBER EACH 33737 "$3,645.00 " 960 "$2,551.50 " "$1,822.50 " "$2,916.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324379 PHYSICIAN FEE - SURGERY PF-REVISION OF HEART VEINS EACH 33645 "$4,861.00 " 960 "$3,402.70 " "$2,430.50 " "$3,888.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313653 PHYSICIAN FEE - SURGERY PF-REVISION OF HIP BONE EACH 27147 "$4,028.00 " 960 "$2,819.60 " "$2,014.00 " "$3,222.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313679 PHYSICIAN FEE - SURGERY PF-REVISION OF HIP BONES EACH 27156 "$4,692.00 " 960 "$3,284.40 " "$2,346.00 " "$3,753.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313497 PHYSICIAN FEE - SURGERY PF-REVISION OF HIP TENDON EACH 27097 "$1,885.00 " 960 "$1,319.50 " $942.50 "$1,508.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309206 PHYSICIAN FEE - SURGERY PF-REVISION OF HUMERUS EACH 24400 "$2,277.00 " 960 "$1,593.90 " "$1,138.50 " "$1,821.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309214 PHYSICIAN FEE - SURGERY PF-REVISION OF HUMERUS EACH 24410 "$2,915.00 " 960 "$2,040.50 " "$1,457.50 " "$2,332.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309222 PHYSICIAN FEE - SURGERY PF-REVISION OF HUMERUS EACH 24420 "$2,910.00 " 960 "$2,037.00 " "$1,455.00 " "$2,328.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334022 PHYSICIAN FEE - SURGERY PF-REVISION OF ILEOSTOMY EACH 44312 "$1,651.00 " 960 "$1,155.70 " $825.50 "$1,320.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334030 PHYSICIAN FEE - SURGERY PF-REVISION OF ILEOSTOMY EACH 44314 "$2,766.00 " 960 "$1,936.20 " "$1,383.00 " "$2,212.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327810 PHYSICIAN FEE - SURGERY PF-REVISION OF INFUSION PUMP EACH 36261 "$1,156.00 " 960 $809.20 $578.00 $924.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351778 PHYSICIAN FEE - SURGERY PF-REVISION OF IRIS EACH 66762 "$1,085.00 " 960 $759.50 $542.50 $868.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305725 PHYSICIAN FEE - SURGERY PF-REVISION OF JAW MUSCLE/BONE EACH 21295 $523.00 960 $366.10 $261.50 $418.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305733 PHYSICIAN FEE - SURGERY PF-REVISION OF JAW MUSCLE/BONE EACH 21296 "$1,086.00 " 960 $760.20 $543.00 $868.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338635 PHYSICIAN FEE - SURGERY PF-REVISION OF KIDNEY/URETER EACH 50400 "$3,061.00 " 960 "$2,142.70 " "$1,530.50 " "$2,448.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338643 PHYSICIAN FEE - SURGERY PF-REVISION OF KIDNEY/URETER EACH 50405 "$3,693.00 " 960 "$2,585.10 " "$1,846.50 " "$2,954.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314891 PHYSICIAN FEE - SURGERY PF-REVISION OF KNEE JOINT EACH 27440 "$2,201.00 " 960 "$1,540.70 " "$1,100.50 " "$1,760.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314909 PHYSICIAN FEE - SURGERY PF-REVISION OF KNEE JOINT EACH 27441 "$2,272.00 " 960 "$1,590.40 " "$1,136.00 " "$1,817.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314917 PHYSICIAN FEE - SURGERY PF-REVISION OF KNEE JOINT EACH 27442 "$2,392.00 " 960 "$1,674.40 " "$1,196.00 " "$1,913.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314925 PHYSICIAN FEE - SURGERY PF-REVISION OF KNEE JOINT EACH 27443 "$2,253.00 " 960 "$1,577.10 " "$1,126.50 " "$1,802.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314933 PHYSICIAN FEE - SURGERY PF-REVISION OF KNEE JOINT EACH 27445 "$3,453.00 " 960 "$2,417.10 " "$1,726.50 " "$2,762.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314941 PHYSICIAN FEE - SURGERY PF-REVISION OF KNEE JOINT EACH 27446 "$3,161.00 " 960 "$2,212.70 " "$1,580.50 " "$2,528.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320856 PHYSICIAN FEE - SURGERY PF-REVISION OF LARYNX EACH 31400 "$2,676.00 " 960 "$1,873.20 " "$1,338.00 " "$2,140.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321185 PHYSICIAN FEE - SURGERY PF-REVISION OF LARYNX EACH 31580 "$3,390.00 " 960 "$2,373.00 " "$1,695.00 " "$2,712.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321219 PHYSICIAN FEE - SURGERY PF-REVISION OF LARYNX EACH 31587 "$3,208.00 " 960 "$2,245.60 " "$1,604.00 " "$2,566.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329378 PHYSICIAN FEE - SURGERY PF-REVISION OF LEG VEIN EACH 37780 $662.00 960 $463.40 $331.00 $529.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302540 PHYSICIAN FEE - SURGERY PF-REVISION OF LOWER EYELID EACH 15820 "$1,329.00 " 960 $930.30 $664.50 "$1,063.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302557 PHYSICIAN FEE - SURGERY PF-REVISION OF LOWER EYELID EACH 15821 "$1,426.00 " 960 $998.20 $713.00 "$1,140.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316177 PHYSICIAN FEE - SURGERY PF-REVISION OF LOWER LEG EACH 27715 "$2,956.00 " 960 "$2,069.20 " "$1,478.00 " "$2,364.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306822 PHYSICIAN FEE - SURGERY PF-REVISION OF LUMBAR SPINE EACH 22214 "$4,328.00 " 960 "$3,029.60 " "$2,164.00 " "$3,462.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306863 PHYSICIAN FEE - SURGERY PF-REVISION OF LUMBAR SPINE EACH 22224 "$4,433.00 " 960 "$3,103.10 " "$2,216.50 " "$3,546.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322753 PHYSICIAN FEE - SURGERY PF-REVISION OF LUNG EACH 32940 "$3,458.00 " 960 "$2,420.60 " "$1,729.00 " "$2,766.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329279 PHYSICIAN FEE - SURGERY PF-REVISION OF MAJOR VEIN EACH 37650 "$1,297.00 " 960 $907.90 $648.50 "$1,037.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329287 PHYSICIAN FEE - SURGERY PF-REVISION OF MAJOR VEIN EACH 37660 "$3,731.00 " 960 "$2,611.70 " "$1,865.50 " "$2,984.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323751 PHYSICIAN FEE - SURGERY PF-REVISION OF MITRAL VALVE EACH 33420 "$4,024.00 " 960 "$2,816.80 " "$2,012.00 " "$3,219.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323769 PHYSICIAN FEE - SURGERY PF-REVISION OF MITRAL VALVE EACH 33422 "$4,611.00 " 960 "$3,227.70 " "$2,305.50 " "$3,688.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306491 PHYSICIAN FEE - SURGERY PF-REVISION OF NECK MUSCLE EACH 21700 "$1,010.00 " 960 $707.00 $505.00 $808.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306517 PHYSICIAN FEE - SURGERY PF-REVISION OF NECK MUSCLE EACH 21720 "$1,558.00 " 960 "$1,090.60 " $779.00 "$1,246.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306525 PHYSICIAN FEE - SURGERY PF-REVISION OF NECK MUSCLE EACH 21725 "$1,498.00 " 960 "$1,048.60 " $749.00 "$1,198.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306509 PHYSICIAN FEE - SURGERY PF-REVISION OF NECK MUSCLE/RIB EACH 21705 "$1,515.00 " 960 "$1,060.50 " $757.50 "$1,212.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306806 PHYSICIAN FEE - SURGERY PF-REVISION OF NECK SPINE EACH 22210 "$5,161.00 " 960 "$3,612.70 " "$2,580.50 " "$4,128.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306848 PHYSICIAN FEE - SURGERY PF-REVISION OF NECK SPINE EACH 22220 "$4,630.00 " 960 "$3,241.00 " "$2,315.00 " "$3,704.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319908 PHYSICIAN FEE - SURGERY PF-REVISION OF NOSE EACH 30120 "$1,120.00 " 960 $784.00 $560.00 $896.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320062 PHYSICIAN FEE - SURGERY PF-REVISION OF NOSE EACH 30430 "$2,827.00 " 960 "$1,978.90 " "$1,413.50 " "$2,261.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320070 PHYSICIAN FEE - SURGERY PF-REVISION OF NOSE EACH 30435 "$3,553.00 " 960 "$2,487.10 " "$1,776.50 " "$2,842.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320088 PHYSICIAN FEE - SURGERY PF-REVISION OF NOSE EACH 30450 "$4,677.00 " 960 "$3,273.90 " "$2,338.50 " "$3,741.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320096 PHYSICIAN FEE - SURGERY PF-REVISION OF NOSE EACH 30460 "$2,231.00 " 960 "$1,561.70 " "$1,115.50 " "$1,784.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320104 PHYSICIAN FEE - SURGERY PF-REVISION OF NOSE EACH 30462 "$4,292.00 " 960 "$3,004.40 " "$2,146.00 " "$3,433.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313687 PHYSICIAN FEE - SURGERY PF-REVISION OF PELVIS EACH 27158 "$3,852.00 " 960 "$2,696.40 " "$1,926.00 " "$3,081.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341597 PHYSICIAN FEE - SURGERY PF-REVISION OF PENIS EACH 54300 "$1,715.00 " 960 "$1,200.50 " $857.50 "$1,372.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341605 PHYSICIAN FEE - SURGERY PF-REVISION OF PENIS EACH 54304 "$1,986.00 " 960 "$1,390.20 " $993.00 "$1,588.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341894 PHYSICIAN FEE - SURGERY PF-REVISION OF PENIS EACH 54420 "$1,868.00 " 960 "$1,307.60 " $934.00 "$1,494.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341902 PHYSICIAN FEE - SURGERY PF-REVISION OF PENIS EACH 54430 "$1,699.00 " 960 "$1,189.30 " $849.50 "$1,359.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341910 PHYSICIAN FEE - SURGERY PF-REVISION OF PENIS EACH 54435 "$1,103.00 " 960 $772.10 $551.50 $882.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323884 PHYSICIAN FEE - SURGERY PF-REVISION OF PULMONARY VALVE EACH 33474 "$6,123.00 " 960 "$4,286.10 " "$3,061.50 " "$4,898.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310394 PHYSICIAN FEE - SURGERY PF-REVISION OF RADIUS EACH 25350 "$1,850.00 " 960 "$1,295.00 " $925.00 "$1,480.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310402 PHYSICIAN FEE - SURGERY PF-REVISION OF RADIUS EACH 25355 "$2,113.00 " 960 "$1,479.10 " "$1,056.50 " "$1,690.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349996 PHYSICIAN FEE - SURGERY PF-REVISION OF SCIATIC NERVE EACH 64712 "$1,642.00 " 960 "$1,149.40 " $821.00 "$1,313.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342298 PHYSICIAN FEE - SURGERY PF-REVISION OF SCROTUM EACH 55175 $974.00 960 $681.80 $487.00 $779.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342306 PHYSICIAN FEE - SURGERY PF-REVISION OF SCROTUM EACH 55180 "$1,836.00 " 960 "$1,285.20 " $918.00 "$1,468.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349160 PHYSICIAN FEE - SURGERY PF-REVISION OF SPINAL SHUNT EACH 63744 "$2,024.00 " 960 "$1,416.80 " "$1,012.00 " "$1,619.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342074 PHYSICIAN FEE - SURGERY PF-REVISION OF TESTIS EACH 54660 $955.00 960 $668.50 $477.50 $764.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314859 PHYSICIAN FEE - SURGERY PF-REVISION OF THIGH MUSCLES EACH 27430 "$2,048.00 " 960 "$1,433.60 " "$1,024.00 " "$1,638.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306814 PHYSICIAN FEE - SURGERY PF-REVISION OF THORAX SPINE EACH 22212 "$4,323.00 " 960 "$3,026.10 " "$2,161.50 " "$3,458.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306855 PHYSICIAN FEE - SURGERY PF-REVISION OF THORAX SPINE EACH 22222 "$5,260.00 " 960 "$3,682.00 " "$2,630.00 " "$4,208.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323819 PHYSICIAN FEE - SURGERY PF-REVISION OF TRICUSPID VALVE EACH 33460 "$6,663.00 " 960 "$4,664.10 " "$3,331.50 " "$5,330.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323850 PHYSICIAN FEE - SURGERY PF-REVISION OF TRICUSPID VALVE EACH 33468 "$6,888.00 " 960 "$4,821.60 " "$3,444.00 " "$5,510.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310410 PHYSICIAN FEE - SURGERY PF-REVISION OF ULNA EACH 25360 "$1,807.00 " 960 "$1,264.90 " $903.50 "$1,445.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309685 PHYSICIAN FEE - SURGERY PF-REVISION OF UPPER ARM EACH 24940 "$2,538.00 " 960 "$1,776.60 " "$1,269.00 " "$2,030.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302565 PHYSICIAN FEE - SURGERY PF-REVISION OF UPPER EYELID EACH 15822 "$1,041.00 " 960 $728.70 $520.50 $832.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302573 PHYSICIAN FEE - SURGERY PF-REVISION OF UPPER EYELID EACH 15823 "$1,423.00 " 960 $996.10 $711.50 "$1,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339047 PHYSICIAN FEE - SURGERY PF-REVISION OF URETER EACH 50700 "$2,457.00 " 960 "$1,719.90 " "$1,228.50 " "$1,965.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341068 PHYSICIAN FEE - SURGERY PF-REVISION OF URETHRA EACH 53450 "$1,088.00 " 960 $761.60 $544.00 $870.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341076 PHYSICIAN FEE - SURGERY PF-REVISION OF URETHRA EACH 53460 "$1,220.00 " 960 $854.00 $610.00 $976.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343205 PHYSICIAN FEE - SURGERY PF-REVISION OF URETHRA EACH 57220 $936.00 960 $655.20 $468.00 $748.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339955 PHYSICIAN FEE - SURGERY PF-REVISION OF URINARY TRACT EACH 51820 "$2,875.00 " 960 "$2,012.50 " "$1,437.50 " "$2,300.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344211 PHYSICIAN FEE - SURGERY PF-REVISION OF UTERUS EACH 58540 "$2,512.00 " 960 "$1,758.40 " "$1,256.00 " "$2,009.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310675 PHYSICIAN FEE - SURGERY PF-REVISION OF WRIST JOINT EACH 25450 "$1,707.00 " 960 "$1,194.90 " $853.50 "$1,365.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310683 PHYSICIAN FEE - SURGERY PF-REVISION OF WRIST JOINT EACH 25455 "$1,689.00 " 960 "$1,182.30 " $844.50 "$1,351.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305691 PHYSICIAN FEE - SURGERY PF-REVISION ORBITOFACIAL BONES EACH 21275 "$2,286.00 " 960 "$1,600.20 " "$1,143.00 " "$1,828.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331630 PHYSICIAN FEE - SURGERY PF-REVISION PHARYNGEAL WALLS EACH 42892 "$4,944.00 " 960 "$3,460.80 " "$2,472.00 " "$3,955.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331648 PHYSICIAN FEE - SURGERY PF-REVISION PHARYNGEAL WALLS EACH 42894 "$6,277.00 " 960 "$4,393.90 " "$3,138.50 " "$5,021.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317514 PHYSICIAN FEE - SURGERY PF-REVISION POST TIBIAL TENDON EACH 28238 "$1,303.00 " 960 $912.10 $651.50 "$1,042.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324833 PHYSICIAN FEE - SURGERY PF-REVISION PULMONARY ARTERY EACH 33788 "$4,303.00 " 960 "$3,012.10 " "$2,151.50 " "$3,442.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323728 PHYSICIAN FEE - SURGERY PF-REVISION SUBVALVULAR TISSUE EACH 33415 "$5,664.00 " 960 "$3,964.80 " "$2,832.00 " "$4,531.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314784 PHYSICIAN FEE - SURGERY PF-REVISION UNSTABLE KNEECAP EACH 27420 "$2,071.00 " 960 "$1,449.70 " "$1,035.50 " "$1,656.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314792 PHYSICIAN FEE - SURGERY PF-REVISION UNSTABLE KNEECAP EACH 27422 "$2,044.00 " 960 "$1,430.80 " "$1,022.00 " "$1,635.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314800 PHYSICIAN FEE - SURGERY PF-REVISION/REMOVAL OF KNEECAP EACH 27424 "$2,067.00 " 960 "$1,446.90 " "$1,033.50 " "$1,653.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361124 PHYSICIAN FEE - SURGERY PF-REVJ/RPLCMT OI IMPLT TC ESP EACH 69719 "$1,725.00 " 960 "$1,207.50 " $862.50 "$1,380.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305501 PHYSICIAN FEE - SURGERY PF-RIB CARTILAGE GRAFT EACH 21230 "$2,017.00 " 960 "$1,411.90 " "$1,008.50 " "$1,613.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502389 PHYSICIAN FEE - SURGERY PF-RLCJ PULSE GEN ONLY ISDSS EACH 0681T $370.00 960 $259.00 $185.00 $296.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361496 PHYSICIAN FEE - SURGERY PF-RMV NTR OI IMP SKT ESP>=100 EACH 69728 "$1,623.00 " 960 "$1,136.10 " $811.50 "$1,298.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358930 PHYSICIAN FEE - SURGERY PF-RMVL DEVITAL TIS 20 CM/< EACH 97597 $92.00 960 $64.40 $46.00 $73.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359771 PHYSICIAN FEE - SURGERY PF-RMVL ESOPHGL SPHNCTR DEV EACH 43285 "$1,901.00 " 960 "$1,330.70 " $950.50 "$1,520.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361058 PHYSICIAN FEE - SURGERY PF-RMVL HPGLSL NSTIM ARY PG EACH 64584 "$1,960.00 " 960 "$1,372.00 " $980.00 "$1,568.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361470 PHYSICIAN FEE - SURGERY PF-RMVL NINFCT MESH HERNIA RPR EACH 49623 $552.00 960 $386.40 $276.00 $441.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354632 PHYSICIAN FEE - SURGERY PF-RMVL OF SUBQ DEFIBRILLATOR EACH 33272 $954.00 960 $667.80 $477.00 $763.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361132 PHYSICIAN FEE - SURGERY PF-RMVL OI IMPLT SKL PERQ ESP EACH 69726 "$1,273.00 " 960 $891.10 $636.50 "$1,018.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361140 PHYSICIAN FEE - SURGERY PF-RMVL OI IMPLT SKL TC ESP EACH 69727 "$1,424.00 " 960 $996.80 $712.00 "$1,139.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359532 PHYSICIAN FEE - SURGERY PF-RMVL SUBQ CAR RHYTHM MNTR EACH 33286 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319031 PHYSICIAN FEE - SURGERY PF-RMVL/BIV SPICA/MINERVA/RISS EACH 29710 $227.00 960 $158.90 $113.50 $181.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359797 PHYSICIAN FEE - SURGERY PF-RPLC GTUBE REVJ GSTRST TRC EACH 43763 $239.00 960 $167.30 $119.50 $191.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361512 PHYSICIAN FEE - SURGERY PF-RPLC OI IMPL SK TC ESP>=100 EACH 69730 "$1,883.00 " 960 "$1,318.10 " $941.50 "$1,506.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359573 PHYSICIAN FEE - SURGERY PF-RPLCMT A-VALVE TLCJ AUTO PV EACH 33440 "$9,448.00 " 960 "$6,613.60 " "$4,724.00 " "$7,558.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361330 PHYSICIAN FEE - SURGERY PF-RPR AA HRN 1ST < 3 CM RDC EACH 49591 $972.00 960 $680.40 $486.00 $777.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361348 PHYSICIAN FEE - SURGERY PF-RPR AA HRN 1ST < 3 NCR/STRN EACH 49592 "$1,355.00 " 960 $948.50 $677.50 "$1,084.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361389 PHYSICIAN FEE - SURGERY PF-RPR AA HRN 1ST > 10 NCR/STR EACH 49596 "$2,909.00 " 960 "$2,036.30 " "$1,454.50 " "$2,327.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361371 PHYSICIAN FEE - SURGERY PF-RPR AA HRN 1ST > 10 RDC EACH 49595 "$2,195.00 " 960 "$1,536.50 " "$1,097.50 " "$1,756.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361363 PHYSICIAN FEE - SURGERY PF-RPR AA HRN 1ST 3-10 NCR/STR EACH 49594 "$2,127.00 " 960 "$1,488.90 " "$1,063.50 " "$1,701.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361355 PHYSICIAN FEE - SURGERY PF-RPR AA HRN 1ST 3-10 RDC EACH 49593 "$1,632.00 " 960 "$1,142.40 " $816.00 "$1,305.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361405 PHYSICIAN FEE - SURGERY PF-RPR AA HRN RCR < 3 NCR/STRN EACH 49614 "$1,626.00 " 960 "$1,138.20 " $813.00 "$1,300.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361397 PHYSICIAN FEE - SURGERY PF-RPR AA HRN RCR < 3 RDC EACH 49613 "$1,197.00 " 960 $837.90 $598.50 $957.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361447 PHYSICIAN FEE - SURGERY PF-RPR AA HRN RCR > 10 NCR/STR EACH 49618 "$3,527.00 " 960 "$2,468.90 " "$1,763.50 " "$2,821.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361439 PHYSICIAN FEE - SURGERY PF-RPR AA HRN RCR > 10 RDC EACH 49617 "$2,513.00 " 960 "$1,759.10 " "$1,256.50 " "$2,010.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361421 PHYSICIAN FEE - SURGERY PF-RPR AA HRN RCR 3-10 NCR/STR EACH 49616 "$2,448.00 " 960 "$1,713.60 " "$1,224.00 " "$1,958.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361413 PHYSICIAN FEE - SURGERY PF-RPR AA HRN RCR 3-10 RDC EACH 49615 "$1,817.00 " 960 "$1,271.90 " $908.50 "$1,453.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337801 PHYSICIAN FEE - SURGERY PF-RPR FEM HERNIA INIT BLOCKED EACH 49553 "$1,789.00 " 960 "$1,252.30 " $894.50 "$1,431.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337678 PHYSICIAN FEE - SURGERY PF-RPR HERN PREEMIE REDUC EACH 49491 "$2,265.00 " 960 "$1,585.50 " "$1,132.50 " "$1,812.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337686 PHYSICIAN FEE - SURGERY PF-RPR ING HERN PREMIE BLOCKED EACH 49492 "$2,726.00 " 960 "$1,908.20 " "$1,363.00 " "$2,180.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337702 PHYSICIAN FEE - SURGERY PF-RPR ING HERNIA BABY BLOCKED EACH 49496 "$1,745.00 " 960 "$1,221.50 " $872.50 "$1,396.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337694 PHYSICIAN FEE - SURGERY PF-RPR ING HERNIA BABY REDUC EACH 49495 "$1,159.00 " 960 $811.30 $579.50 $927.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337728 PHYSICIAN FEE - SURGERY PF-RPR ING HERNIA INIT BLOCKED EACH 49501 "$1,720.00 " 960 "$1,204.00 " $860.00 "$1,376.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337710 PHYSICIAN FEE - SURGERY PF-RPR ING HERNIA INIT REDUCE EACH 49500 "$1,174.00 " 960 $821.80 $587.00 $939.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301542 PHYSICIAN FEE - SURGERY PF-RPR LAC INT FACE >30.0CM EACH 12057 "$1,137.00 " 960 $795.90 $568.50 $909.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301526 PHYSICIAN FEE - SURGERY PF-RPR LAC INT FACE 12.6-20.CM EACH 12055 $818.00 960 $572.60 $409.00 $654.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301492 PHYSICIAN FEE - SURGERY PF-RPR LAC INT FACE 2.6-5.0CM EACH 12052 $525.00 960 $367.50 $262.50 $420.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301534 PHYSICIAN FEE - SURGERY PF-RPR LAC INT FACE 20.1-30.CM EACH 12056 "$1,038.00 " 960 $726.60 $519.00 $830.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301500 PHYSICIAN FEE - SURGERY PF-RPR LAC INT FACE 5.1-7.5CM EACH 12053 $568.00 960 $397.60 $284.00 $454.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301518 PHYSICIAN FEE - SURGERY PF-RPR LAC INT FACE 7.6-12.5CM EACH 12054 $590.00 960 $413.00 $295.00 $472.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301484 PHYSICIAN FEE - SURGERY PF-RPR LAC INT FCE/EAR 2.5CM+ EACH 12051 $448.00 960 $313.60 $224.00 $358.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301377 PHYSICIAN FEE - SURGERY PF-RPR LAC INT SC/AXIL 2.6-7.5 EACH 12032 $498.00 960 $348.60 $249.00 $398.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301369 PHYSICIAN FEE - SURGERY PF-RPR LAC INT SC/AXL TO 2.5CM EACH 12031 $398.00 960 $278.60 $199.00 $318.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301336 PHYSICIAN FEE - SURGERY PF-RPR LAC SMP FACE >30.0 CM EACH 12018 $492.00 960 $344.40 $246.00 $393.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301310 PHYSICIAN FEE - SURGERY PF-RPR LAC SMP FACE 12.1-20.CM EACH 12016 $360.00 960 $252.00 $180.00 $288.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301328 PHYSICIAN FEE - SURGERY PF-RPR LAC SMP FACE 20.1-30.CM EACH 12017 $438.00 960 $306.60 $219.00 $350.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301294 PHYSICIAN FEE - SURGERY PF-RPR LAC SMP FACE 5.1-7.5CM EACH 12014 $212.00 960 $148.40 $106.00 $169.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301302 PHYSICIAN FEE - SURGERY PF-RPR LAC SMP FACE 7.6-12.5CM EACH 12015 $266.00 960 $186.20 $133.00 $212.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301229 PHYSICIAN FEE - SURGERY PF-RPR LAC SMP SCALP 2.6-7.5CM EACH 12002 $164.00 960 $114.80 $82.00 $131.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301211 PHYSICIAN FEE - SURGERY PF-RPR LAC SMP SCALP TO 2.5 CM EACH 12001 $125.00 960 $87.50 $62.50 $100.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361231 PHYSICIAN FEE - SURGERY PF-RPR NSL VLV COLLAPSE W/RMDL EACH 30469 $404.00 960 $282.80 $202.00 $323.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361454 PHYSICIAN FEE - SURGERY PF-RPR PARASTOMAL HERNIA RDC EACH 49621 "$2,088.00 " 960 "$1,461.60 " "$1,044.00 " "$1,670.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361462 PHYSICIAN FEE - SURGERY PF-RPR PARASTOMAL HRNA NCR/STR EACH 49622 "$2,572.00 " 960 "$1,800.40 " "$1,286.00 " "$2,057.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325178 PHYSICIAN FEE - SURGERY PF-RPR PUL ART UNIFOCAL WO CPB EACH 33925 "$4,820.00 " 960 "$3,374.00 " "$2,410.00 " "$3,856.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337793 PHYSICIAN FEE - SURGERY PF-RPR REM HERNIA INIT REDUCE EACH 49550 "$1,636.00 " 960 "$1,145.20 " $818.00 "$1,308.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313406 PHYSICIAN FEE - SURGERY PF-RSECT HIP TUM INCL FEMUR EACH 27078 "$5,653.00 " 960 "$3,957.10 " "$2,826.50 " "$4,522.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334238 PHYSICIAN FEE - SURGERY PF-S BOWEL ENDOSCOPE W/STENT EACH 44379 "$1,072.00 " 960 $750.40 $536.00 $857.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347156 PHYSICIAN FEE - SURGERY PF-SCAN PROC CRANIAL EXTRA EACH 61782 $464.00 960 $324.80 $232.00 $371.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347149 PHYSICIAN FEE - SURGERY PF-SCAN PROC CRANIAL INTRA EACH 61781 $714.00 960 $499.80 $357.00 $571.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347164 PHYSICIAN FEE - SURGERY PF-SCAN PROC SPINAL EACH 61783 $686.00 960 $480.20 $343.00 $548.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319676 PHYSICIAN FEE - SURGERY PF-SCOPE PLANTAR FASCIOTOMY EACH 29893 "$1,149.00 " 960 $804.30 $574.50 $919.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328750 PHYSICIAN FEE - SURGERY PF-SEC ART M-THROMBECT ADD-ON EACH 37186 $671.00 960 $469.70 $335.50 $536.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354566 PHYSICIAN FEE - SURGERY PF-SECOND LEVEL CER DISKECTOMY EACH 22858 "$1,462.00 " 960 "$1,023.40 " $731.00 "$1,169.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341712 PHYSICIAN FEE - SURGERY PF-SECONDARY URETHRAL SURGERY EACH 54340 "$1,517.00 " 960 "$1,061.90 " $758.50 "$1,213.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341720 PHYSICIAN FEE - SURGERY PF-SECONDARY URETHRAL SURGERY EACH 54344 "$2,506.00 " 960 "$1,754.20 " "$1,253.00 " "$2,004.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341738 PHYSICIAN FEE - SURGERY PF-SECONDARY URETHRAL SURGERY EACH 54348 "$2,679.00 " 960 "$1,875.30 " "$1,339.50 " "$2,143.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322100 PHYSICIAN FEE - SURGERY PF-SEGMENTECTOMY EACH 32484 "$4,016.00 " 960 "$2,811.20 " "$2,008.00 " "$3,212.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353220 PHYSICIAN FEE - SURGERY PF-SEPARATE EYELID ADHESIONS EACH 68340 "$1,023.00 " 960 $716.10 $511.50 $818.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350218 PHYSICIAN FEE - SURGERY PF-SEVER CRANIAL NERVE EACH 64771 "$1,582.00 " 960 "$1,107.40 " $791.00 "$1,265.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310477 PHYSICIAN FEE - SURGERY PF-SHORTEN RADIUS & ULNA EACH 25392 "$2,792.00 " 960 "$1,954.40 " "$1,396.00 " "$2,233.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310451 PHYSICIAN FEE - SURGERY PF-SHORTEN RADIUS OR ULNA EACH 25390 "$2,108.00 " 960 "$1,475.60 " "$1,054.00 " "$1,686.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315039 PHYSICIAN FEE - SURGERY PF-SHORTEN/LENGTHEN THIGHS EACH 27468 "$3,691.00 " 960 "$2,583.70 " "$1,845.50 " "$2,952.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312085 PHYSICIAN FEE - SURGERY PF-SHORTENING OF HAND TENDON EACH 26479 "$1,817.00 " 960 "$1,271.90 " $908.50 "$1,453.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315013 PHYSICIAN FEE - SURGERY PF-SHORTENING OF THIGH BONE EACH 27465 "$3,437.00 " 960 "$2,405.90 " "$1,718.50 " "$2,749.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319106 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY DX EACH 29805 "$1,283.00 " 960 $898.10 $641.50 "$1,026.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319189 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29824 "$1,857.00 " 960 "$1,299.90 " $928.50 "$1,485.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319114 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29806 "$2,908.00 " 960 "$2,035.60 " "$1,454.00 " "$2,326.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319122 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29807 "$2,839.00 " 960 "$1,987.30 " "$1,419.50 " "$2,271.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319130 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29819 "$1,612.00 " 960 "$1,128.40 " $806.00 "$1,289.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319148 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29820 "$1,463.00 " 960 "$1,024.10 " $731.50 "$1,170.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319155 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29821 "$1,627.00 " 960 "$1,138.90 " $813.50 "$1,301.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319163 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29822 "$1,487.00 " 960 "$1,040.90 " $743.50 "$1,189.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319171 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29823 "$1,629.00 " 960 "$1,140.30 " $814.50 "$1,303.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319197 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29825 "$1,607.00 " 960 "$1,124.90 " $803.50 "$1,285.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319205 PHYSICIAN FEE - SURGERY PF-SHOULDER ARTHROSCOPY/SURG EACH 29826 $471.00 960 $329.70 $235.50 $376.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307705 PHYSICIAN FEE - SURGERY PF-SHOULDER JOINT SURGERY EACH 23101 "$1,267.00 " 960 $886.90 $633.50 "$1,013.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354582 PHYSICIAN FEE - SURGERY PF-SHOULDER PROSTHESIS REMOVAL EACH 23334 "$2,900.00 " 960 "$2,030.00 " "$1,450.00 " "$2,320.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354590 PHYSICIAN FEE - SURGERY PF-SHOULDER PROSTHESIS REMOVAL EACH 23335 "$3,478.00 " 960 "$2,434.60 " "$1,739.00 " "$2,782.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300445 PHYSICIAN FEE - SURGERY PF-SHV LESN FACE/EAR .6-1.0CM EACH 11311 $165.00 960 $115.50 $82.50 $132.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300460 PHYSICIAN FEE - SURGERY PF-SHV LESN FACE/EAR >2.0CM EACH 11313 $252.00 960 $176.40 $126.00 $201.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300452 PHYSICIAN FEE - SURGERY PF-SHV LESN FACE/EAR 1.1-2.0CM EACH 11312 $194.00 960 $135.80 $97.00 $155.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300437 PHYSICIAN FEE - SURGERY PF-SHV LESN FACE/EAR TO 0.5CM EACH 11310 $120.00 960 $84.00 $60.00 $96.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300411 PHYSICIAN FEE - SURGERY PF-SHV LESN SKN SCA 1.1-2.0 CM EACH 11307 $164.00 960 $114.80 $82.00 $131.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300395 PHYSICIAN FEE - SURGERY PF-SHV LESN SKN SCALP TO 0.5CM EACH 11305 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300379 PHYSICIAN FEE - SURGERY PF-SHV LESN TRNK/ARM 1.1-2.0CM EACH 11302 $156.00 960 $109.20 $78.00 $124.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300361 PHYSICIAN FEE - SURGERY PF-SHV LESN TRUNK/ARM .6-1.0CM EACH 11301 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300353 PHYSICIAN FEE - SURGERY PF-SHV LESN TRUNK/ARM TO 0.5CM EACH 11300 $90.00 960 $63.00 $45.00 $72.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335037 PHYSICIAN FEE - SURGERY PF-SIG W/BALLOON DILATION EACH 45340 $209.00 960 $146.30 $104.50 $167.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357601 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/BAND LIG EACH 45350 $268.00 960 $187.60 $134.00 $214.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335011 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY & DECOMPRESS EACH 45337 $303.00 960 $212.10 $151.50 $242.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334980 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY & POLYPECTOMY EACH 45333 $252.00 960 $176.40 $126.00 $201.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334998 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY FOR BLEEDING EACH 45334 $309.00 960 $216.30 $154.50 $247.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358591 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/ABLATION EACH 34709 $906.00 960 $634.20 $453.00 $724.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359896 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/ABLATION EACH 45346 $422.00 960 $295.40 $211.00 $337.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334972 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/FB REMOVAL EACH 45332 $280.00 960 $196.00 $140.00 $224.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359904 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/PLCMT STENT EACH 45347 $405.00 960 $283.50 $202.50 $324.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358641 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/RESECTION EACH 34714 $756.00 960 $529.20 $378.00 $604.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359912 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/RESECTION EACH 45349 $518.00 960 $362.60 $259.00 $414.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335003 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/SUBMUC INJ EACH 45335 $177.00 960 $123.90 $88.50 $141.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335029 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/TUMR REMOVE EACH 45338 $317.00 960 $221.90 $158.50 $253.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335045 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/ULTRASOUND EACH 45341 $325.00 960 $227.50 $162.50 $260.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335052 PHYSICIAN FEE - SURGERY PF-SIGMOIDOSCOPY W/US GUIDE BX EACH 45342 $451.00 960 $315.70 $225.50 $360.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339823 PHYSICIAN FEE - SURGERY PF-SIMPLE CYSTOMETROGRAM EACH 51725 $199.00 960 $139.30 $99.50 $159.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312416 PHYSICIAN FEE - SURGERY PF-SINGLE TRANSFER TOE-HAND EACH 26553 "$8,972.00 " 960 "$6,280.40 " "$4,486.00 " "$7,177.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320708 PHYSICIAN FEE - SURGERY PF-SINUS ENDO W/BALLOON DIL EACH 31295 $423.00 960 $296.10 $211.50 $338.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320724 PHYSICIAN FEE - SURGERY PF-SINUS ENDO W/BALLOON DIL EACH 31297 $387.00 960 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320716 PHYSICIAN FEE - SURGERY PF-SINUS ENDO W/BALLOON DIL EACH 31296 $480.00 960 $336.00 $240.00 $384.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320625 PHYSICIAN FEE - SURGERY PF-SINUS ENDOSCOPY SURGICAL EACH 31276 "$1,016.00 " 960 $711.20 $508.00 $812.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302706 PHYSICIAN FEE - SURGERY PF-SKIN AND MUSCLE REPAIR FACE EACH 15845 "$2,872.00 " 960 "$2,010.40 " "$1,436.00 " "$2,297.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302060 PHYSICIAN FEE - SURGERY PF-SKIN FULL GRAFT ADD-ON EACH 15221 $188.00 960 $131.60 $94.00 $150.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302094 PHYSICIAN FEE - SURGERY PF-SKIN FULL GRAFT EEN & LIPS EACH 15260 "$2,221.00 " 960 "$1,554.70 " "$1,110.50 " "$1,776.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302052 PHYSICIAN FEE - SURGERY PF-SKIN FULL GRAFT SCLP/ARM/LG EACH 15220 "$1,623.00 " 960 "$1,136.10 " $811.50 "$1,298.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302037 PHYSICIAN FEE - SURGERY PF-SKIN FULL GRAFT TRUNK EACH 15200 "$1,819.00 " 960 "$1,273.30 " $909.50 "$1,455.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302045 PHYSICIAN FEE - SURGERY PF-SKIN FULL GRAFT TRUNK ADDON EACH 15201 $209.00 960 $146.30 $104.50 $167.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302078 PHYSICIAN FEE - SURGERY PF-SKIN FULL GRFT FACE/GEN/HF EACH 15240 "$2,107.00 " 960 "$1,474.90 " "$1,053.50 " "$1,685.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302235 PHYSICIAN FEE - SURGERY PF-SKIN GRAFT EACH 15600 $566.00 960 $396.20 $283.00 $452.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302243 PHYSICIAN FEE - SURGERY PF-SKIN GRAFT EACH 15610 $654.00 960 $457.80 $327.00 $523.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302250 PHYSICIAN FEE - SURGERY PF-SKIN GRAFT EACH 15620 $870.00 960 $609.00 $435.00 $696.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303332 PHYSICIAN FEE - SURGERY PF-SKIN PEEL THERAPY EACH 17360 $245.00 960 $171.50 $122.50 $196.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301849 PHYSICIAN FEE - SURGERY PF-SKIN PINCH GRAFT EACH 15050 "$1,229.00 " 960 $860.30 $614.50 $983.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301864 PHYSICIAN FEE - SURGERY PF-SKIN SPLT GRFT T/A/L ADD-ON EACH 15101 $306.00 960 $214.20 $153.00 $244.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301856 PHYSICIAN FEE - SURGERY PF-SKIN SPLT GRFT TRNK/ARM/LEG EACH 15100 "$1,946.00 " 960 "$1,362.20 " $973.00 "$1,556.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302169 PHYSICIAN FEE - SURGERY PF-SKIN SUB GRAFT F/N/HF/G ADL EACH 15276 $68.00 960 $47.60 $34.00 $54.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302151 PHYSICIAN FEE - SURGERY PF-SKIN SUB GRAFT FACE/NK/HF/G EACH 15275 $246.00 960 $172.20 $123.00 $196.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302128 PHYSICIAN FEE - SURGERY PF-SKIN SUB GRAFT T/A/L ADD-ON EACH 15272 $46.00 960 $32.20 $23.00 $36.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302110 PHYSICIAN FEE - SURGERY PF-SKIN SUB GRAFT TRNK/ARM/LEG EACH 15271 $226.00 960 $158.20 $113.00 $180.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302136 PHYSICIAN FEE - SURGERY PF-SKIN SUB GRFT T/ARM/LG CH EACH 15273 $534.00 960 $373.80 $267.00 $427.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303340 PHYSICIAN FEE - SURGERY PF-SKIN TISSUE PROCEDURE EACH 17999 $146.00 960 $102.20 $73.00 $116.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301773 PHYSICIAN FEE - SURGERY PF-SKIN TISSUE REARRANGE ADDON EACH 14302 $587.00 960 $410.90 $293.50 $469.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301716 PHYSICIAN FEE - SURGERY PF-SKIN TISSUE REARRANGEMENT EACH 14021 "$1,880.00 " 960 "$1,316.00 " $940.00 "$1,504.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301781 PHYSICIAN FEE - SURGERY PF-SKIN TISSUE REARRANGEMENT EACH 14350 "$1,778.00 " 960 "$1,244.60 " $889.00 "$1,422.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301765 PHYSICIAN FEE - SURGERY PF-SKIN TISSUE REARRANGEMENT EACH 14301 "$2,332.00 " 960 "$1,632.40 " "$1,166.00 " "$1,865.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301922 PHYSICIAN FEE - SURGERY PF-SKN SPLT A-GRFT F/N/HF/G AD EACH 15121 $359.00 960 $251.30 $179.50 $287.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301914 PHYSICIAN FEE - SURGERY PF-SKN SPLT A-GRFT F/NCK/HF/G EACH 15120 "$1,859.00 " 960 "$1,301.30 " $929.50 "$1,487.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302185 PHYSICIAN FEE - SURGERY PF-SKN SUB GRFT F/N/HF/G CH AD EACH 15278 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302177 PHYSICIAN FEE - SURGERY PF-SKN SUB GRFT F/N/HF/G CHILD EACH 15277 $607.00 960 $424.90 $303.50 $485.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346570 PHYSICIAN FEE - SURGERY PF-SKULL BASE/BRAINSTEM SURG EACH 61575 "$7,568.00 " 960 "$5,297.60 " "$3,784.00 " "$6,054.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346588 PHYSICIAN FEE - SURGERY PF-SKULL BASE/BRAINSTEM SURG EACH 61576 "$12,398.00 " 960 "$8,678.60 " "$6,199.00 " "$9,918.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322118 PHYSICIAN FEE - SURGERY PF-SLEEVE LOBECTOMY EACH 32486 "$6,584.00 " 960 "$4,608.80 " "$3,292.00 " "$5,267.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322068 PHYSICIAN FEE - SURGERY PF-SLEEVE PNEUMONECTOMY EACH 32442 "$8,589.00 " 960 "$6,012.30 " "$4,294.50 " "$6,871.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341266 PHYSICIAN FEE - SURGERY PF-SLITTING OF PREPUCE EACH 54000 $294.00 960 $205.80 $147.00 $235.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341274 PHYSICIAN FEE - SURGERY PF-SLITTING OF PREPUCE EACH 54001 $374.00 960 $261.80 $187.00 $299.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334113 PHYSICIAN FEE - SURGERY PF-SM BOWEL ENDOSCOPY/BIOPSY EACH 44361 $416.00 960 $291.20 $208.00 $332.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334212 PHYSICIAN FEE - SURGERY PF-SM BOWEL ENDOSCOPY/BIOPSY EACH 44377 $785.00 960 $549.50 $392.50 $628.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334105 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44360 $378.00 960 $264.60 $189.00 $302.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334121 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44363 $502.00 960 $351.40 $251.00 $401.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334139 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44364 $534.00 960 $373.80 $267.00 $427.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334147 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44365 $479.00 960 $335.30 $239.50 $383.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334154 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44366 $626.00 960 $438.20 $313.00 $500.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334162 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44369 $642.00 960 $449.40 $321.00 $513.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334188 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44372 $632.00 960 $442.40 $316.00 $505.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334196 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44373 $503.00 960 $352.10 $251.50 $402.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334204 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44376 $740.00 960 $518.00 $370.00 $592.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334220 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44378 "$1,005.00 " 960 $703.50 $502.50 $804.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334246 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44380 $152.00 960 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334253 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44382 $195.00 960 $136.50 $97.50 $156.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359292 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY EACH 44384 $402.00 960 $281.40 $201.00 $321.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359805 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY BR/WA EACH 44381 $224.00 960 $156.80 $112.00 $179.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334170 PHYSICIAN FEE - SURGERY PF-SMALL BOWEL ENDOSCOPY/STENT EACH 44370 $698.00 960 $488.60 $349.00 $558.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357569 PHYSICIAN FEE - SURGERY PF-SP BONE AGRFT LOCAL ADD-ON EACH 20936 $348.00 960 $243.60 $174.00 $278.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304546 PHYSICIAN FEE - SURGERY PF-SP BONE AGRFT MORSEL ADD-ON EACH 20937 $479.00 960 $335.30 $239.50 $383.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304553 PHYSICIAN FEE - SURGERY PF-SP BONE AGRFT STRUCT ADD-ON EACH 20938 $536.00 960 $375.20 $268.00 $428.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304538 PHYSICIAN FEE - SURGERY PF-SP BONE ALGRFT STRUCT ADDON EACH 20931 $323.00 960 $226.10 $161.50 $258.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344112 PHYSICIAN FEE - SURGERY PF-SPERM WASHING EACH 58323 $34.00 960 $23.80 $17.00 $27.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320369 PHYSICIAN FEE - SURGERY PF-SPHENOID SINUS SURGERY EACH 31051 "$1,835.00 " 960 "$1,284.50 " $917.50 "$1,468.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348154 PHYSICIAN FEE - SURGERY PF-SPINAL DISK SURGERY ADD-ON EACH 63035 $679.00 960 $475.30 $339.50 $543.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307101 PHYSICIAN FEE - SURGERY PF-SPINE & SKULL SPINAL FUSION EACH 22590 "$4,691.00 " 960 "$3,283.70 " "$2,345.50 " "$3,752.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348337 PHYSICIAN FEE - SURGERY PF-SPINE DISK SURGERY THORAX EACH 63077 "$4,031.00 " 960 "$2,821.70 " "$2,015.50 " "$3,224.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348345 PHYSICIAN FEE - SURGERY PF-SPINE DISK SURGERY THORAX EACH 63078 $627.00 960 $438.90 $313.50 $501.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307150 PHYSICIAN FEE - SURGERY PF-SPINE FUSION EXTRA SEGMENT EACH 22614 "$1,141.00 " 960 $798.70 $570.50 $912.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307176 PHYSICIAN FEE - SURGERY PF-SPINE FUSION EXTRA SEGMENT EACH 22632 $949.00 960 $664.30 $474.50 $759.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307192 PHYSICIAN FEE - SURGERY PF-SPINE FUSION EXTRA SEGMENT EACH 22634 "$1,414.00 " 960 $989.80 $707.00 "$1,131.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328701 PHYSICIAN FEE - SURGERY PF-SPLICE SPLEEN/KIDNEY VEINS EACH 37181 "$6,593.00 " 960 "$4,615.10 " "$3,296.50 " "$5,274.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339138 PHYSICIAN FEE - SURGERY PF-SPLICING OF URETERS EACH 50770 "$3,054.00 " 960 "$2,137.80 " "$1,527.00 " "$2,443.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347222 PHYSICIAN FEE - SURGERY PF-SRS CRAN LES COMPLEX ADDL EACH 61799 $594.00 960 $415.80 $297.00 $475.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347206 PHYSICIAN FEE - SURGERY PF-SRS CRAN LES SIMPLE ADDL EACH 61797 $667.00 960 $466.90 $333.50 $533.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347214 PHYSICIAN FEE - SURGERY PF-SRS CRANIAL LESION COMPLEX EACH 61798 "$4,157.00 " 960 "$2,909.90 " "$2,078.50 " "$3,325.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347198 PHYSICIAN FEE - SURGERY PF-SRS CRANIAL LESION SIMPLE EACH 61796 "$3,058.00 " 960 "$2,140.60 " "$1,529.00 " "$2,446.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348972 PHYSICIAN FEE - SURGERY PF-SRS SPINAL LESION EACH 63620 "$3,391.00 " 960 "$2,373.70 " "$1,695.50 " "$2,712.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348980 PHYSICIAN FEE - SURGERY PF-SRS SPINAL LESION ADDL EACH 63621 $765.00 960 $535.50 $382.50 $612.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329352 PHYSICIAN FEE - SURGERY PF-STAB PHLEB VEINS XTR 10-20 EACH 37765 $751.00 960 $525.70 $375.50 $600.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354939 PHYSICIAN FEE - SURGERY PF-STENT PLACEMT RETRO CAROTID EACH 37217 "$3,024.00 " 960 "$2,116.80 " "$1,512.00 " "$2,419.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306459 PHYSICIAN FEE - SURGERY PF-STERNAL DEBRIDEMENT EACH 21627 "$1,515.00 " 960 "$1,060.50 " $757.50 "$1,212.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348956 PHYSICIAN FEE - SURGERY PF-STIMULATION OF SPINAL CORD EACH 63610 "$1,751.00 " 960 "$1,225.70 " $875.50 "$1,400.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357593 PHYSICIAN FEE - SURGERY PF-STOMACH SURGERY PROC NOS EACH 43999 $937.00 960 $655.90 $468.50 $749.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318777 PHYSICIAN FEE - SURGERY PF-STRAPPING OF HAND OR FINGER EACH 29280 $54.00 960 $37.80 $27.00 $43.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318959 PHYSICIAN FEE - SURGERY PF-STRAPPING OF TOES EACH 29550 $29.00 960 $20.30 $14.50 $23.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350606 PHYSICIAN FEE - SURGERY PF-SUBSEQUENT REPAIR OF NERVE EACH 64872 $317.00 960 $221.90 $158.50 $253.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319783 PHYSICIAN FEE - SURGERY PF-SUBTALAR ARTHRO W/DEB EACH 29906 "$1,767.00 " 960 "$1,236.90 " $883.50 "$1,413.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319775 PHYSICIAN FEE - SURGERY PF-SUBTALAR ARTHRO W/EXC EACH 29905 "$1,348.00 " 960 $943.60 $674.00 "$1,078.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319767 PHYSICIAN FEE - SURGERY PF-SUBTALAR ARTHRO W/FB RMVL EACH 29904 "$1,764.00 " 960 "$1,234.80 " $882.00 "$1,411.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319791 PHYSICIAN FEE - SURGERY PF-SUBTALAR ARTHRO W/FUSION EACH 29907 "$2,417.00 " 960 "$1,691.90 " "$1,208.50 " "$1,933.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346083 PHYSICIAN FEE - SURGERY PF-SUBTEMPORAL DECOMPRESSION EACH 61340 "$4,337.00 " 960 "$3,035.90 " "$2,168.50 " "$3,469.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358716 PHYSICIAN FEE - SURGERY PF-SUCTION LIPECTOMY; TRUNK EACH 38222 $194.00 960 $135.80 $97.00 $155.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335375 PHYSICIAN FEE - SURGERY PF-SURG DX EXAM ANORECTAL EACH 45990 $289.00 960 $202.30 $144.50 $231.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336282 PHYSICIAN FEE - SURGERY PF-SURGERY FOR LIVER LESION EACH 47300 "$3,207.00 " 960 "$2,244.90 " "$1,603.50 " "$2,565.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340847 PHYSICIAN FEE - SURGERY PF-SURGERY FOR URETHRA POUCH EACH 53240 "$1,132.00 " 960 $792.40 $566.00 $905.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342710 PHYSICIAN FEE - SURGERY PF-SURGERY FOR VULVA LESION EACH 56440 $496.00 960 $347.20 $248.00 $396.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303860 PHYSICIAN FEE - SURGERY PF-SURGERY OF BREAST CAPSULE EACH 19370 "$1,824.00 " 960 "$1,276.80 " $912.00 "$1,459.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325129 PHYSICIAN FEE - SURGERY PF-SURGERY OF GREAT VESSEL EACH 33916 "$11,630.00 " 960 "$8,141.00 " "$5,815.00 " "$9,304.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337025 PHYSICIAN FEE - SURGERY PF-SURGERY OF PANCREATIC CYST EACH 48500 "$3,250.00 " 960 "$2,275.00 " "$1,625.00 " "$2,600.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315062 PHYSICIAN FEE - SURGERY PF-SURGERY TO STOP LEG GROWTH EACH 27475 "$1,831.00 " 960 "$1,281.70 " $915.50 "$1,464.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315070 PHYSICIAN FEE - SURGERY PF-SURGERY TO STOP LEG GROWTH EACH 27477 "$2,026.00 " 960 "$1,418.20 " "$1,013.00 " "$1,620.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315088 PHYSICIAN FEE - SURGERY PF-SURGERY TO STOP LEG GROWTH EACH 27479 "$2,533.00 " 960 "$1,773.10 " "$1,266.50 " "$2,026.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315096 PHYSICIAN FEE - SURGERY PF-SURGERY TO STOP LEG GROWTH EACH 27485 "$1,854.00 " 960 "$1,297.80 " $927.00 "$1,483.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321300 PHYSICIAN FEE - SURGERY PF-SURGERY/SPEECH PROSTHESIS EACH 31611 "$1,423.00 " 960 $996.10 $711.50 "$1,138.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342603 PHYSICIAN FEE - SURGERY PF-SURGICAL EXPOSURE PROSTATE EACH 55860 "$2,319.00 " 960 "$1,623.30 " "$1,159.50 " "$1,855.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332737 PHYSICIAN FEE - SURGERY PF-SURGICAL OPENING ESOPHAGUS EACH 43351 "$3,704.00 " 960 "$2,592.80 " "$1,852.00 " "$2,963.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332745 PHYSICIAN FEE - SURGERY PF-SURGICAL OPENING ESOPHAGUS EACH 43352 "$2,996.00 " 960 "$2,097.20 " "$1,498.00 " "$2,396.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332885 PHYSICIAN FEE - SURGERY PF-SURGICAL OPENING OF STOMACH EACH 43500 "$2,227.00 " 960 "$1,558.90 " "$1,113.50 " "$1,781.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332919 PHYSICIAN FEE - SURGERY PF-SURGICAL OPENING OF STOMACH EACH 43510 "$2,694.00 " 960 "$1,885.80 " "$1,347.00 " "$2,155.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331689 PHYSICIAN FEE - SURGERY PF-SURGICAL OPENING OF THROAT EACH 42955 "$1,997.00 " 960 "$1,397.90 " $998.50 "$1,597.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332893 PHYSICIAN FEE - SURGERY PF-SURGICAL REPAIR OF STOMACH EACH 43501 "$3,832.00 " 960 "$2,682.40 " "$1,916.00 " "$3,065.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332901 PHYSICIAN FEE - SURGERY PF-SURGICAL REPAIR OF STOMACH EACH 43502 "$4,339.00 " 960 "$3,037.30 " "$2,169.50 " "$3,471.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334477 PHYSICIAN FEE - SURGERY PF-SURGICAL REVISION INTESTINE EACH 44680 "$3,058.00 " 960 "$2,140.60 " "$1,529.00 " "$2,446.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334485 PHYSICIAN FEE - SURGERY PF-SUSPEND BOWEL W/PROSTHESIS EACH 44700 "$2,737.00 " 960 "$1,915.90 " "$1,368.50 " "$2,189.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98303696 PHYSICIAN FEE - SURGERY PF-SUSPENSION OF BREAST EACH 19316 "$2,162.00 " 960 "$1,513.40 " "$1,081.00 " "$1,729.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342041 PHYSICIAN FEE - SURGERY PF-SUSPENSION OF TESTIS EACH 54620 $793.00 960 $555.10 $396.50 $634.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342058 PHYSICIAN FEE - SURGERY PF-SUSPENSION OF TESTIS EACH 54640 "$1,155.00 " 960 $808.50 $577.50 $924.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344187 PHYSICIAN FEE - SURGERY PF-SUSPENSION OF UTERUS EACH 58400 "$1,257.00 " 960 $879.90 $628.50 "$1,005.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344195 PHYSICIAN FEE - SURGERY PF-SUSPENSION OF UTERUS EACH 58410 "$2,232.00 " 960 "$1,562.40 " "$1,116.00 " "$1,785.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343296 PHYSICIAN FEE - SURGERY PF-SUSPENSION OF VAGINA EACH 57280 "$2,625.00 " 960 "$1,837.50 " "$1,312.50 " "$2,100.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336845 PHYSICIAN FEE - SURGERY PF-SUTURE BILE DUCT INJURY EACH 47900 "$3,908.00 " 960 "$2,735.60 " "$1,954.00 " "$3,126.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334378 PHYSICIAN FEE - SURGERY PF-SUTURE LARGE INTESTINE EACH 44604 "$2,959.00 " 960 "$2,071.30 " "$1,479.50 " "$2,367.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334352 PHYSICIAN FEE - SURGERY PF-SUTURE SMALL INTESTINE EACH 44602 "$3,972.00 " 960 "$2,780.40 " "$1,986.00 " "$3,177.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98334360 PHYSICIAN FEE - SURGERY PF-SUTURE SMALL INTESTINE EACH 44603 "$4,535.00 " 960 "$3,174.50 " "$2,267.50 " "$3,628.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317035 PHYSICIAN FEE - SURGERY PF-SYNOVECT INTERTAR/TAR JT EA EACH 28070 $907.00 960 $634.90 $453.50 $725.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344773 PHYSICIAN FEE - SURGERY PF-TAH RAD DEBULK/LYMPH REMOVE EACH 58954 "$5,932.00 " 960 "$4,152.40 " "$2,966.00 " "$4,745.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344765 PHYSICIAN FEE - SURGERY PF-TAH RAD DISSECT FOR DEBULK EACH 58953 "$5,475.00 " 960 "$3,832.50 " "$2,737.50 " "$4,380.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358344 PHYSICIAN FEE - SURGERY PF-TANGENTIAL SKIN BIOPSY ADDL EACH 11103 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356942 PHYSICIAN FEE - SURGERY PF-TAP BLOCK UNI BY INF BI EACH 64489 $201.00 960 $140.70 $100.50 $160.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356660 PHYSICIAN FEE - SURGERY PF-TAP BLOCK UNI BY INF LT EACH 64487 $165.00 960 $115.50 $82.50 $132.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356926 PHYSICIAN FEE - SURGERY PF-TAP BLOCK UNI BY INF RT EACH 64487 $165.00 960 $115.50 $82.50 $132.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356934 PHYSICIAN FEE - SURGERY PF-TAP BLOCK UNI BY INJ BI EACH 64488 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98356918 PHYSICIAN FEE - SURGERY PF-TAP BLOCK UNIL BY INJ RT EACH 64486 $144.00 960 $100.80 $72.00 $115.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359540 PHYSICIAN FEE - SURGERY PF-TCAT IMPL WRLS P-ART PRS SN EACH 33289 $922.00 960 $645.40 $461.00 $737.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359508 PHYSICIAN FEE - SURGERY PF-TCAT INSJ/RPL PERM LDLS PM EACH 33274 "$1,314.00 " 960 $919.80 $657.00 "$1,051.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502447 PHYSICIAN FEE - SURGERY PF-TCAT PLMT&RMVL CEPD PERQ EACH 33370 $370.00 960 $259.00 $185.00 $296.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359516 PHYSICIAN FEE - SURGERY PF-TCAT RMVL PERM LDLS PM EACH 33275 "$1,397.00 " 960 $977.90 $698.50 "$1,117.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358757 PHYSICIAN FEE - SURGERY PF-TEAR DUCT SYSTEM SURG NOS EACH 43288 "$10,531.00 " 960 "$7,371.70 " "$5,265.50 " "$8,424.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354194 PHYSICIAN FEE - SURGERY PF-TEMPLE BONE IMPL REVISION EACH 69717 "$1,502.00 " 960 "$1,051.40 " $751.00 "$1,201.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329212 PHYSICIAN FEE - SURGERY PF-TEMPORAL ARTERY PROCEDURE EACH 37609 $560.00 960 $392.00 $280.00 $448.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311566 PHYSICIAN FEE - SURGERY PF-TENDON EXCISION PALM/FINGER EACH 26145 "$1,417.00 " 960 $991.90 $708.50 "$1,133.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312051 PHYSICIAN FEE - SURGERY PF-TENDON LENGTHENING EACH 26476 "$1,729.00 " 960 "$1,210.30 " $864.50 "$1,383.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312069 PHYSICIAN FEE - SURGERY PF-TENDON SHORTENING EACH 26477 "$1,681.00 " 960 "$1,176.70 " $840.50 "$1,344.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312143 PHYSICIAN FEE - SURGERY PF-TENDON TRANSFER WITH GRAFT EACH 26492 "$2,514.00 " 960 "$1,759.80 " "$1,257.00 " "$2,011.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309016 PHYSICIAN FEE - SURGERY PF-TENOLYSIS TRICEPS EACH 24332 "$1,700.00 " 960 "$1,190.00 " $850.00 "$1,360.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302748 PHYSICIAN FEE - SURGERY PF-TEST FOR BLOOD FLOW IN GRFT EACH 15860 $293.00 960 $205.10 $146.50 $234.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98320286 PHYSICIAN FEE - SURGERY PF-THER FX NASAL INF TURBINATE EACH 30930 $315.00 960 $220.50 $157.50 $252.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361538 PHYSICIAN FEE - SURGERY PF-THER SPI PNXR CSF FLUOR/CT EACH 62329 $281.00 960 $196.70 $140.50 $224.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322761 PHYSICIAN FEE - SURGERY PF-THERAPEUTIC PNEUMOTHORAX EACH 32960 $234.00 960 $163.80 $117.00 $187.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332687 PHYSICIAN FEE - SURGERY PF-THORABD DIAPHR HERN REPAIR EACH 43336 "$4,073.00 " 960 "$2,851.10 " "$2,036.50 " "$3,258.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332695 PHYSICIAN FEE - SURGERY PF-THORABD DIAPHR HERN REPAIR EACH 43337 "$4,341.00 " 960 "$3,038.70 " "$2,170.50 " "$3,472.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325012 PHYSICIAN FEE - SURGERY PF-THORACIC AORTIC GRAFT EACH 33875 "$7,677.00 " 960 "$5,373.90 " "$3,838.50 " "$6,141.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329600 PHYSICIAN FEE - SURGERY PF-THORACIC DUCT PROCEDURE EACH 38380 "$1,570.00 " 960 "$1,099.00 " $785.00 "$1,256.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329618 PHYSICIAN FEE - SURGERY PF-THORACIC DUCT PROCEDURE EACH 38381 "$2,258.00 " 960 "$1,580.60 " "$1,129.00 " "$1,806.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329626 PHYSICIAN FEE - SURGERY PF-THORACIC DUCT PROCEDURE EACH 38382 "$1,912.00 " 960 "$1,338.40 " $956.00 "$1,529.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325020 PHYSICIAN FEE - SURGERY PF-THORACOABDOMINAL GRAFT EACH 33877 "$10,125.00 " 960 "$7,087.50 " "$5,062.50 " "$8,100.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322563 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY BILOBECTOMY EACH 32670 "$4,480.00 " 960 "$3,136.00 " "$2,240.00 " "$3,584.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322324 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY DIAGNOSTIC EACH 32601 $862.00 960 $603.40 $431.00 $689.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322332 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY DIAGNOSTIC EACH 32604 "$1,348.00 " 960 $943.60 $674.00 "$1,078.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322340 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY DIAGNOSTIC EACH 32606 "$1,295.00 " 960 $906.50 $647.50 "$1,036.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322589 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY FOR LVRS EACH 32672 "$4,258.00 " 960 "$2,980.60 " "$2,129.00 " "$3,406.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322605 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY LYMPH NODE EXC EACH 32674 $607.00 960 $424.90 $303.50 $485.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322571 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY PNEUMONECTOMY EACH 32671 "$4,977.00 " 960 "$3,483.90 " "$2,488.50 " "$3,981.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322555 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY REMOVE SEGMENT EACH 32669 "$3,762.00 " 960 "$2,633.40 " "$1,881.00 " "$3,009.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322381 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32650 "$1,862.00 " 960 "$1,303.40 " $931.00 "$1,489.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322399 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32651 "$3,065.00 " 960 "$2,145.50 " "$1,532.50 " "$2,452.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322407 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32652 "$4,658.00 " 960 "$3,260.60 " "$2,329.00 " "$3,726.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322415 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32653 "$2,947.00 " 960 "$2,062.90 " "$1,473.50 " "$2,357.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322423 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32654 "$3,291.00 " 960 "$2,303.70 " "$1,645.50 " "$2,632.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322431 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32655 "$2,677.00 " 960 "$1,873.90 " "$1,338.50 " "$2,141.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322449 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32656 "$2,244.00 " 960 "$1,570.80 " "$1,122.00 " "$1,795.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322456 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32658 "$1,999.00 " 960 "$1,399.30 " $999.50 "$1,599.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322464 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32659 "$2,050.00 " 960 "$1,435.00 " "$1,025.00 " "$1,640.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322472 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32661 "$2,238.00 " 960 "$1,566.60 " "$1,119.00 " "$1,790.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322480 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32662 "$2,503.00 " 960 "$1,752.10 " "$1,251.50 " "$2,002.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322498 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32663 "$3,919.00 " 960 "$2,743.30 " "$1,959.50 " "$3,135.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322506 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32664 "$2,377.00 " 960 "$1,663.90 " "$1,188.50 " "$1,901.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322514 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY SURGICAL EACH 32665 "$3,453.00 " 960 "$2,417.10 " "$1,726.50 " "$2,762.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322365 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY W/BX NODULE EACH 32608 "$1,062.00 " 960 $743.40 $531.00 $849.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322373 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY W/BX PLEURA EACH 32609 $707.00 960 $494.90 $353.50 $565.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322522 PHYSICIAN FEE - SURGERY PF-THORACOSCOPY W/WEDGE RESECT EACH 32666 "$2,434.00 " 960 "$1,703.80 " "$1,217.00 " "$1,947.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322357 PHYSICIAN FEE - SURGERY PF-THORACOSCPY W/BX INFILTRATE EACH 32607 $860.00 960 $602.00 $430.00 $688.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322597 PHYSICIAN FEE - SURGERY PF-THORACOSCPY W/THYMUS RESECT EACH 32673 "$3,405.00 " 960 "$2,383.50 " "$1,702.50 " "$2,724.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322530 PHYSICIAN FEE - SURGERY PF-THORACOSCPY W/W RESECT ADDL EACH 32667 $441.00 960 $308.70 $220.50 $352.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322548 PHYSICIAN FEE - SURGERY PF-THORACOSCPY W/W RESECT DIAG EACH 32668 $441.00 960 $308.70 $220.50 $352.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307069 PHYSICIAN FEE - SURGERY PF-THORAX SPINE FUSION EACH 22556 "$4,881.00 " 960 "$3,416.70 " "$2,440.50 " "$3,904.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98307135 PHYSICIAN FEE - SURGERY PF-THORAX SPINE FUSION EACH 22610 "$3,713.00 " 960 "$2,599.10 " "$1,856.50 " "$2,970.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322613 PHYSICIAN FEE - SURGERY PF-THORX STEREO RAD TARGETW/TX EACH 32701 $575.00 960 $402.50 $287.50 $460.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331762 PHYSICIAN FEE - SURGERY PF-THROAT MUSCLE SURGERY EACH 43030 "$1,418.00 " 960 $992.60 $709.00 "$1,134.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357866 PHYSICIAN FEE - SURGERY PF-THROAT SURGERY PROC NOS EACH 42999 $968.00 960 $677.60 $484.00 $774.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328818 PHYSICIAN FEE - SURGERY PF-THROMBOLYTIC THERAPY STROKE EACH 37195 "$1,018.00 " 960 $712.60 $509.00 $814.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312903 PHYSICIAN FEE - SURGERY PF-THUMB FUSION WITH GRAFT EACH 26820 "$2,243.00 " 960 "$1,570.10 " "$1,121.50 " "$1,794.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312929 PHYSICIAN FEE - SURGERY PF-THUMB FUSION WITH GRAFT EACH 26842 "$2,250.00 " 960 "$1,575.00 " "$1,125.00 " "$1,800.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312234 PHYSICIAN FEE - SURGERY PF-THUMB TENDON TRANSFER EACH 26510 "$1,715.00 " 960 "$1,200.50 " $857.50 "$1,372.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329014 PHYSICIAN FEE - SURGERY PF-TIB/PER REVASC STENT&ATHER EACH 37231 "$1,987.00 " 960 "$1,390.90 " $993.50 "$1,589.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329055 PHYSICIAN FEE - SURGERY PF-TIB/PER REVASC STNT & ATHER EACH 37235 $975.00 960 $682.50 $487.50 $780.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328990 PHYSICIAN FEE - SURGERY PF-TIB/PER REVASC W/ATHER EACH 37229 "$1,897.00 " 960 "$1,327.90 " $948.50 "$1,517.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329006 PHYSICIAN FEE - SURGERY PF-TIB/PER REVASC W/STENT EACH 37230 "$1,912.00 " 960 "$1,338.40 " $956.00 "$1,529.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319387 PHYSICIAN FEE - SURGERY PF-TIBIAL ARTHROSCOPY/SURGERY EACH 29855 "$2,143.00 " 960 "$1,500.10 " "$1,071.50 " "$1,714.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319395 PHYSICIAN FEE - SURGERY PF-TIBIAL ARTHROSCOPY/SURGERY EACH 29856 "$2,734.00 " 960 "$1,913.80 " "$1,367.00 " "$2,187.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301724 PHYSICIAN FEE - SURGERY PF-TIS XFR F/C/M/N/A/H/F <10CM EACH 14040 "$1,649.00 " 960 "$1,154.30 " $824.50 "$1,319.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301732 PHYSICIAN FEE - SURGERY PF-TIS XFR F/C/M/N/A/H/F >10CM EACH 14041 "$2,008.00 " 960 "$1,405.60 " "$1,004.00 " "$1,606.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344419 PHYSICIAN FEE - SURGERY PF-TLH UTERUS 250 G OR LESS EACH 58570 "$2,205.00 " 960 "$1,543.50 " "$1,102.50 " "$1,764.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344435 PHYSICIAN FEE - SURGERY PF-TLH UTERUS OVER 250 G EACH 58572 "$2,779.00 " 960 "$1,945.30 " "$1,389.50 " "$2,223.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344427 PHYSICIAN FEE - SURGERY PF-TLH W/T/O 250 G OR LESS EACH 58571 "$2,485.00 " 960 "$1,739.50 " "$1,242.50 " "$1,988.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344443 PHYSICIAN FEE - SURGERY PF-TLH W/T/O UTERUS OVER 250 G EACH 58573 "$3,336.00 " 960 "$2,335.20 " "$1,668.00 " "$2,668.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312440 PHYSICIAN FEE - SURGERY PF-TOE JOINT TRANSFER EACH 26556 "$9,329.00 " 960 "$6,530.30 " "$4,664.50 " "$7,463.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330624 PHYSICIAN FEE - SURGERY PF-TONGUE AND NECK SURGERY EACH 41135 "$5,733.00 " 960 "$4,013.10 " "$2,866.50 " "$4,586.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330756 PHYSICIAN FEE - SURGERY PF-TONGUE BASE VOL REDUCTION EACH 41530 $985.00 960 $689.50 $492.50 $788.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330673 PHYSICIAN FEE - SURGERY PF-TONGUE JAW & NECK SURGERY EACH 41155 "$7,906.00 " 960 "$5,534.20 " "$3,953.00 " "$6,324.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330657 PHYSICIAN FEE - SURGERY PF-TONGUE MOUTH JAW SURGERY EACH 41150 "$5,812.00 " 960 "$4,068.40 " "$2,906.00 " "$4,649.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330665 PHYSICIAN FEE - SURGERY PF-TONGUE MOUTH NECK SURGERY EACH 41153 "$6,333.00 " 960 "$4,433.10 " "$3,166.50 " "$5,066.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330640 PHYSICIAN FEE - SURGERY PF-TONGUE REMOVAL NECK SURGERY EACH 41145 "$7,264.00 " 960 "$5,084.80 " "$3,632.00 " "$5,811.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330731 PHYSICIAN FEE - SURGERY PF-TONGUE SUSPENSION EACH 41512 "$1,751.00 " 960 "$1,225.70 " $875.50 "$1,400.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330723 PHYSICIAN FEE - SURGERY PF-TONGUE TO LIP SURGERY EACH 41510 "$1,182.00 " 960 $827.40 $591.00 $945.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358583 PHYSICIAN FEE - SURGERY PF-TONGUE/MOUTH SURGERY NOS EACH 34708 "$5,147.00 " 960 "$3,602.90 " "$2,573.50 " "$4,117.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313588 PHYSICIAN FEE - SURGERY PF-TOTAL HIP ARTHROPLASTY EACH 27130 "$3,538.00 " 960 "$2,476.60 " "$1,769.00 " "$2,830.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313596 PHYSICIAN FEE - SURGERY PF-TOTAL HIP ARTHROPLASTY EACH 27132 "$4,597.00 " 960 "$3,217.90 " "$2,298.50 " "$3,677.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343882 PHYSICIAN FEE - SURGERY PF-TOTAL HYSTERECTOMY EACH 58150 "$2,779.00 " 960 "$1,945.30 " "$1,389.50 " "$2,223.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343890 PHYSICIAN FEE - SURGERY PF-TOTAL HYSTERECTOMY EACH 58152 "$3,392.00 " 960 "$2,374.40 " "$1,696.00 " "$2,713.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314958 PHYSICIAN FEE - SURGERY PF-TOTAL KNEE ARTHROPLASTY EACH 27447 "$3,531.00 " 960 "$2,471.70 " "$1,765.50 " "$2,824.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322779 PHYSICIAN FEE - SURGERY PF-TOTAL LUNG LAVAGE EACH 32997 $865.00 960 $605.50 $432.50 $692.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360977 PHYSICIAN FEE - SURGERY PF-TPRNL BAL CNTNC DEV RMVL EA EACH 53453 $557.00 960 $389.90 $278.50 $445.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360985 PHYSICIAN FEE - SURGERY PF-TPRNL BALO CNTNC DEV ADJMT EACH 53454 "$2,409.00 " 960 "$1,686.30 " "$1,204.50 " "$1,927.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360951 PHYSICIAN FEE - SURGERY PF-TPRNL BALO CNTNC DEV BI EACH 53451 "$2,917.00 " 960 "$2,041.90 " "$1,458.50 " "$2,333.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360969 PHYSICIAN FEE - SURGERY PF-TPRNL BALO CNTNC DEV UNI EACH 53452 $747.00 960 $522.90 $373.50 $597.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352297 PHYSICIAN FEE - SURGERY PF-TR RETINAL LES PRETERM INF EACH 67229 "$2,954.00 " 960 "$2,067.80 " "$1,477.00 " "$2,363.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332570 PHYSICIAN FEE - SURGERY PF-TRACHEO-ESOPHAGOPLASTY CONG EACH 43314 "$8,840.00 " 960 "$6,188.00 " "$4,420.00 " "$7,072.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332646 PHYSICIAN FEE - SURGERY PF-TRANSAB ESOPH HIAT HERN RPR EACH 43332 "$3,249.00 " 960 "$2,274.30 " "$1,624.50 " "$2,599.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332653 PHYSICIAN FEE - SURGERY PF-TRANSAB ESOPH HIAT HERN RPR EACH 43333 "$3,560.00 " 960 "$2,492.00 " "$1,780.00 " "$2,848.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344948 PHYSICIAN FEE - SURGERY PF-TRANSABDOM AMNIOINFUS W/US EACH 59070 $899.00 960 $629.30 $449.50 $719.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346885 PHYSICIAN FEE - SURGERY PF-TRANSCATH OCCLUSION CNS EACH 61624 "$3,398.00 " 960 "$2,378.60 " "$1,699.00 " "$2,718.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346711 PHYSICIAN FEE - SURGERY PF-TRANSCONDYLR APPROACH/SKULL EACH 61597 "$8,790.00 " 960 "$6,153.00 " "$4,395.00 " "$7,032.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346802 PHYSICIAN FEE - SURGERY PF-TRANSECT ARTERY SINUS EACH 61611 "$1,417.00 " 960 $991.90 $708.50 "$1,133.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325152 PHYSICIAN FEE - SURGERY PF-TRANSECT PULMONARY ARTERY EACH 33922 "$2,922.00 " 960 "$2,045.40 " "$1,461.00 " "$2,337.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313513 PHYSICIAN FEE - SURGERY PF-TRANSFER ABDOMINAL MUSCLE EACH 27100 "$2,288.00 " 960 "$1,601.60 " "$1,144.00 " "$1,830.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313539 PHYSICIAN FEE - SURGERY PF-TRANSFER ILIOPSOAS MUSCLE EACH 27110 "$2,674.00 " 960 "$1,871.80 " "$1,337.00 " "$2,139.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313547 PHYSICIAN FEE - SURGERY PF-TRANSFER ILIOPSOAS MUSCLE EACH 27111 "$2,489.00 " 960 "$1,742.30 " "$1,244.50 " "$1,991.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344831 PHYSICIAN FEE - SURGERY PF-TRANSFER OF EMBRYO EACH 58974 $360.00 960 $252.00 $180.00 $288.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344849 PHYSICIAN FEE - SURGERY PF-TRANSFER OF EMBRYO EACH 58976 $578.00 960 $404.60 $289.00 $462.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313521 PHYSICIAN FEE - SURGERY PF-TRANSFER OF SPINAL MUSCLE EACH 27105 "$2,399.00 " 960 "$1,679.30 " "$1,199.50 " "$1,919.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98302276 PHYSICIAN FEE - SURGERY PF-TRANSFER SKIN PEDICLE FLAP EACH 15650 "$1,088.00 " 960 $761.60 $544.00 $870.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313505 PHYSICIAN FEE - SURGERY PF-TRANSFER TENDON TO PELVIS EACH 27098 "$1,918.00 " 960 "$1,342.60 " $959.00 "$1,534.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327935 PHYSICIAN FEE - SURGERY PF-TRANSFUSION SERVICE FETAL EACH 36460 $941.00 960 $658.70 $470.50 $752.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351547 PHYSICIAN FEE - SURGERY PF-TRANSLUM DIL EYE CANAL EACH 66174 "$1,594.00 " 960 "$1,115.80 " $797.00 "$1,275.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360944 PHYSICIAN FEE - SURGERY PF-TRANSOR LWR ESOPHGL MYOTOMY EACH 43497 "$2,105.00 " 960 "$1,473.50 " "$1,052.50 " "$1,684.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342660 PHYSICIAN FEE - SURGERY PF-TRANSPERI NEEDLE PLACE PROS EACH 55875 "$2,052.00 " 960 "$1,436.40 " "$1,026.00 " "$1,641.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346729 PHYSICIAN FEE - SURGERY PF-TRANSPETROSL APPROACH/SKULL EACH 61598 "$8,442.00 " 960 "$5,909.40 " "$4,221.00 " "$6,753.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337116 PHYSICIAN FEE - SURGERY PF-TRANSPL ALLOGRAFT PANCREAS EACH 48554 "$7,359.00 " 960 "$5,151.30 " "$3,679.50 " "$5,887.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313638 PHYSICIAN FEE - SURGERY PF-TRANSPLANT FEMUR RIDGE EACH 27140 "$2,473.00 " 960 "$1,731.10 " "$1,236.50 " "$1,978.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310311 PHYSICIAN FEE - SURGERY PF-TRANSPLANT FOREARM TENDON EACH 25310 "$1,704.00 " 960 "$1,192.80 " $852.00 "$1,363.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310329 PHYSICIAN FEE - SURGERY PF-TRANSPLANT FOREARM TENDON EACH 25312 "$1,969.00 " 960 "$1,378.30 " $984.50 "$1,575.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312093 PHYSICIAN FEE - SURGERY PF-TRANSPLANT HAND TENDON EACH 26480 "$2,095.00 " 960 "$1,466.50 " "$1,047.50 " "$1,676.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314677 PHYSICIAN FEE - SURGERY PF-TRANSPLANT OF THIGH TENDON EACH 27396 "$1,708.00 " 960 "$1,195.60 " $854.00 "$1,366.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312119 PHYSICIAN FEE - SURGERY PF-TRANSPLANT PALM TENDON EACH 26485 "$2,239.00 " 960 "$1,567.30 " "$1,119.50 " "$1,791.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314685 PHYSICIAN FEE - SURGERY PF-TRANSPLANT THIGH TENDONS EACH 27397 "$2,524.00 " 960 "$1,766.80 " "$1,262.00 " "$2,019.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339260 PHYSICIAN FEE - SURGERY PF-TRANSPLANT URETER TO SKIN EACH 50860 "$2,507.00 " 960 "$1,754.90 " "$1,253.50 " "$2,005.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312101 PHYSICIAN FEE - SURGERY PF-TRANSPLANT/GRFT HAND TENDON EACH 26483 "$2,336.00 " 960 "$1,635.20 " "$1,168.00 " "$1,868.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312127 PHYSICIAN FEE - SURGERY PF-TRANSPLANT/GRFT PALM TENDON EACH 26489 "$2,604.00 " 960 "$1,822.80 " "$1,302.00 " "$2,083.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325202 PHYSICIAN FEE - SURGERY PF-TRANSPLANTATION HEART/LUNG EACH 33935 "$13,677.00 " 960 "$9,573.90 " "$6,838.50 " "$10,941.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325228 PHYSICIAN FEE - SURGERY PF-TRANSPLANTATION OF HEART EACH 33945 "$13,589.00 " 960 "$9,512.30 " "$6,794.50 " "$10,871.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338452 PHYSICIAN FEE - SURGERY PF-TRANSPLANTATION OF KIDNEY EACH 50360 "$6,875.00 " 960 "$4,812.50 " "$3,437.50 " "$5,500.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338460 PHYSICIAN FEE - SURGERY PF-TRANSPLANTATION OF KIDNEY EACH 50365 "$8,170.00 " 960 "$5,719.00 " "$4,085.00 " "$6,536.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336183 PHYSICIAN FEE - SURGERY PF-TRANSPLANTATION OF LIVER EACH 47135 "$15,273.00 " 960 "$10,691.10 " "$7,636.50 " "$12,218.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98329568 PHYSICIAN FEE - SURGERY PF-TRANSPLJ HEMATOPOIET BOOST EACH 38243 $316.00 960 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325566 PHYSICIAN FEE - SURGERY PF-TRANSPOSITION OF VEIN VALVE EACH 34510 "$2,887.00 " 960 "$2,020.90 " "$1,443.50 " "$2,309.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344674 PHYSICIAN FEE - SURGERY PF-TRANSPOSITION OVARY(S) EACH 58825 "$1,615.00 " 960 "$1,130.50 " $807.50 "$1,292.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346695 PHYSICIAN FEE - SURGERY PF-TRANSTEMPOR APPROACH/SKULL EACH 61595 "$6,703.00 " 960 "$4,692.10 " "$3,351.50 " "$5,362.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98324346 PHYSICIAN FEE - SURGERY PF-TRANSTHOR CATH FOR STENT EACH 33621 "$2,606.00 " 960 "$1,824.20 " "$1,303.00 " "$2,084.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332661 PHYSICIAN FEE - SURGERY PF-TRANSTHOR DIAPHRAG HERN RPR EACH 43334 "$3,486.00 " 960 "$2,440.20 " "$1,743.00 " "$2,788.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332679 PHYSICIAN FEE - SURGERY PF-TRANSTHOR DIAPHRAG HERN RPR EACH 43335 "$3,756.00 " 960 "$2,629.20 " "$1,878.00 " "$3,004.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341258 PHYSICIAN FEE - SURGERY PF-TRANSURETHRAL RF TREATMENT EACH 53860 $592.00 960 $414.40 $296.00 $473.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354657 PHYSICIAN FEE - SURGERY PF-TRCATH REPLACE AORTIC VALVE EACH 33366 "$4,360.00 " 960 "$3,052.00 " "$2,180.00 " "$3,488.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316631 PHYSICIAN FEE - SURGERY PF-TREAT ANKLE DISLOCATION EACH 27840 "$1,078.00 " 960 $754.60 $539.00 $862.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316649 PHYSICIAN FEE - SURGERY PF-TREAT ANKLE DISLOCATION EACH 27842 "$1,358.00 " 960 $950.60 $679.00 "$1,086.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316656 PHYSICIAN FEE - SURGERY PF-TREAT ANKLE DISLOCATION EACH 27846 "$1,998.00 " 960 "$1,398.60 " $999.00 "$1,598.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316664 PHYSICIAN FEE - SURGERY PF-TREAT ANKLE DISLOCATION EACH 27848 "$2,156.00 " 960 "$1,509.20 " "$1,078.00 " "$1,724.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318108 PHYSICIAN FEE - SURGERY PF-TREAT BIG TOE FRACTURE EACH 28490 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318116 PHYSICIAN FEE - SURGERY PF-TREAT BIG TOE FRACTURE EACH 28495 $401.00 960 $280.70 $200.50 $320.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305915 PHYSICIAN FEE - SURGERY PF-TREAT CHEEK BONE FRACTURE EACH 21355 $882.00 960 $617.40 $441.00 $705.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305923 PHYSICIAN FEE - SURGERY PF-TREAT CHEEK BONE FRACTURE EACH 21356 "$1,089.00 " 960 $762.30 $544.50 $871.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305931 PHYSICIAN FEE - SURGERY PF-TREAT CHEEK BONE FRACTURE EACH 21360 "$1,411.00 " 960 $987.70 $705.50 "$1,128.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305949 PHYSICIAN FEE - SURGERY PF-TREAT CHEEK BONE FRACTURE EACH 21365 "$2,894.00 " 960 "$2,025.80 " "$1,447.00 " "$2,315.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305956 PHYSICIAN FEE - SURGERY PF-TREAT CHEEK BONE FRACTURE EACH 21366 "$3,462.00 " 960 "$2,423.40 " "$1,731.00 " "$2,769.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321987 PHYSICIAN FEE - SURGERY PF-TREAT CHEST LINING EACH 32215 "$2,246.00 " 960 "$1,572.20 " "$1,123.00 " "$1,796.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308265 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE DISLOCATION EACH 23530 "$1,590.00 " 960 "$1,113.00 " $795.00 "$1,272.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308240 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE DISLOCATION EACH 23520 $664.00 960 $464.80 $332.00 $531.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308257 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE DISLOCATION EACH 23525 "$1,008.00 " 960 $705.60 $504.00 $806.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308273 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE DISLOCATION EACH 23532 "$1,730.00 " 960 "$1,211.00 " $865.00 "$1,384.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308281 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE DISLOCATION EACH 23540 $658.00 960 $460.60 $329.00 $526.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308299 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE DISLOCATION EACH 23545 $905.00 960 $633.50 $452.50 $724.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308307 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE DISLOCATION EACH 23550 "$1,577.00 " 960 "$1,103.90 " $788.50 "$1,261.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308315 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE DISLOCATION EACH 23552 "$1,785.00 " 960 "$1,249.50 " $892.50 "$1,428.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308216 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE FRACTURE EACH 23500 $621.00 960 $434.70 $310.50 $496.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308224 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE FRACTURE EACH 23505 $932.00 960 $652.40 $466.00 $745.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308232 PHYSICIAN FEE - SURGERY PF-TREAT CLAVICLE FRACTURE EACH 23515 "$1,981.00 " 960 "$1,386.70 " $990.50 "$1,584.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306095 PHYSICIAN FEE - SURGERY PF-TREAT CRANIOFACIAL FRACTURE EACH 21431 "$1,791.00 " 960 "$1,253.70 " $895.50 "$1,432.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306103 PHYSICIAN FEE - SURGERY PF-TREAT CRANIOFACIAL FRACTURE EACH 21432 "$1,915.00 " 960 "$1,340.50 " $957.50 "$1,532.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306111 PHYSICIAN FEE - SURGERY PF-TREAT CRANIOFACIAL FRACTURE EACH 21433 "$4,704.00 " 960 "$3,292.80 " "$2,352.00 " "$3,763.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306129 PHYSICIAN FEE - SURGERY PF-TREAT CRANIOFACIAL FRACTURE EACH 21435 "$3,814.00 " 960 "$2,669.80 " "$1,907.00 " "$3,051.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306137 PHYSICIAN FEE - SURGERY PF-TREAT CRANIOFACIAL FRACTURE EACH 21436 "$5,525.00 " 960 "$3,867.50 " "$2,762.50 " "$4,420.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306145 PHYSICIAN FEE - SURGERY PF-TREAT DENTAL RIDGE FRACTURE EACH 21440 "$1,553.00 " 960 "$1,087.10 " $776.50 "$1,242.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306152 PHYSICIAN FEE - SURGERY PF-TREAT DENTAL RIDGE FRACTURE EACH 21445 "$1,629.00 " 960 "$1,140.30 " $814.50 "$1,303.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308455 PHYSICIAN FEE - SURGERY PF-TREAT DISLOCATION/FRACTURE EACH 23665 "$1,117.00 " 960 $781.90 $558.50 $893.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308463 PHYSICIAN FEE - SURGERY PF-TREAT DISLOCATION/FRACTURE EACH 23670 "$2,404.00 " 960 "$1,682.80 " "$1,202.00 " "$1,923.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308471 PHYSICIAN FEE - SURGERY PF-TREAT DISLOCATION/FRACTURE EACH 23675 "$1,396.00 " 960 $977.20 $698.00 "$1,116.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308489 PHYSICIAN FEE - SURGERY PF-TREAT DISLOCATION/FRACTURE EACH 23680 "$2,528.00 " 960 "$1,769.60 " "$1,264.00 " "$2,022.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306962 PHYSICIAN FEE - SURGERY PF-TREAT EACH ADD SPINE FX EACH 22328 $827.00 960 $578.90 $413.50 $661.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344997 PHYSICIAN FEE - SURGERY PF-TREAT ECTOPIC PREGNANCY EACH 59120 "$2,373.00 " 960 "$1,661.10 " "$1,186.50 " "$1,898.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345002 PHYSICIAN FEE - SURGERY PF-TREAT ECTOPIC PREGNANCY EACH 59121 "$2,376.00 " 960 "$1,663.20 " "$1,188.00 " "$1,900.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345010 PHYSICIAN FEE - SURGERY PF-TREAT ECTOPIC PREGNANCY EACH 59130 "$2,762.00 " 960 "$1,933.40 " "$1,381.00 " "$2,209.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345036 PHYSICIAN FEE - SURGERY PF-TREAT ECTOPIC PREGNANCY EACH 59136 "$2,621.00 " 960 "$1,834.70 " "$1,310.50 " "$2,096.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345044 PHYSICIAN FEE - SURGERY PF-TREAT ECTOPIC PREGNANCY EACH 59140 "$1,203.00 " 960 $842.10 $601.50 $962.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345051 PHYSICIAN FEE - SURGERY PF-TREAT ECTOPIC PREGNANCY EACH 59150 "$2,302.00 " 960 "$1,611.40 " "$1,151.00 " "$1,841.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345069 PHYSICIAN FEE - SURGERY PF-TREAT ECTOPIC PREGNANCY EACH 59151 "$2,255.00 " 960 "$1,578.50 " "$1,127.50 " "$1,804.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309479 PHYSICIAN FEE - SURGERY PF-TREAT ELBOW DISLOCATION EACH 24600 $962.00 960 $673.40 $481.00 $769.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309487 PHYSICIAN FEE - SURGERY PF-TREAT ELBOW DISLOCATION EACH 24605 "$1,322.00 " 960 $925.40 $661.00 "$1,057.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309495 PHYSICIAN FEE - SURGERY PF-TREAT ELBOW DISLOCATION EACH 24615 "$1,965.00 " 960 "$1,375.50 " $982.50 "$1,572.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309529 PHYSICIAN FEE - SURGERY PF-TREAT ELBOW DISLOCATION EACH 24640 $209.00 960 $146.30 $104.50 $167.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309453 PHYSICIAN FEE - SURGERY PF-TREAT ELBOW FRACTURE EACH 24586 "$2,986.00 " 960 "$2,090.20 " "$1,493.00 " "$2,388.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309461 PHYSICIAN FEE - SURGERY PF-TREAT ELBOW FRACTURE EACH 24587 "$3,001.00 " 960 "$2,100.70 " "$1,500.50 " "$2,400.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309503 PHYSICIAN FEE - SURGERY PF-TREAT ELBOW FRACTURE EACH 24620 "$1,628.00 " 960 "$1,139.60 " $814.00 "$1,302.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309511 PHYSICIAN FEE - SURGERY PF-TREAT ELBOW FRACTURE EACH 24635 "$1,857.00 " 960 "$1,299.90 " $928.50 "$1,485.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305964 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21385 "$1,979.00 " 960 "$1,385.30 " $989.50 "$1,583.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305972 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21386 "$1,877.00 " 960 "$1,313.90 " $938.50 "$1,501.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305980 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21387 "$2,067.00 " 960 "$1,446.90 " "$1,033.50 " "$1,653.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305998 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21390 "$2,131.00 " 960 "$1,491.70 " "$1,065.50 " "$1,704.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306004 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21395 "$2,734.00 " 960 "$1,913.80 " "$1,367.00 " "$2,187.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306012 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21400 $454.00 960 $317.80 $227.00 $363.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306020 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21401 $890.00 960 $623.00 $445.00 $712.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306038 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21406 "$1,579.00 " 960 "$1,105.30 " $789.50 "$1,263.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306046 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21407 "$1,701.00 " 960 "$1,190.70 " $850.50 "$1,360.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306053 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET FRACTURE EACH 21408 "$2,446.00 " 960 "$1,712.20 " "$1,223.00 " "$1,956.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352495 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET W/REM FB EACH 67413 "$2,463.00 " 960 "$1,724.10 " "$1,231.50 " "$1,970.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352487 PHYSICIAN FEE - SURGERY PF-TREAT EYE SOCKET W/REM LES EACH 67412 "$2,529.00 " 960 "$1,770.30 " "$1,264.50 " "$2,023.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353154 PHYSICIAN FEE - SURGERY PF-TREAT EYELID BY INJECTION EACH 68200 $88.00 960 $61.60 $44.00 $70.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312861 PHYSICIAN FEE - SURGERY PF-TREAT FINGER DISLOCATION EACH 26770 $738.00 960 $516.60 $369.00 $590.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312879 PHYSICIAN FEE - SURGERY PF-TREAT FINGER DISLOCATION EACH 26775 $984.00 960 $688.80 $492.00 $787.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312895 PHYSICIAN FEE - SURGERY PF-TREAT FINGER DISLOCATION EACH 26785 "$1,501.00 " 960 "$1,050.70 " $750.50 "$1,200.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312804 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26742 $933.00 960 $653.10 $466.50 $746.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312754 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26720 $527.00 960 $368.90 $263.50 $421.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312762 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26725 $850.00 960 $595.00 $425.00 $680.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312770 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26727 "$1,304.00 " 960 $912.80 $652.00 "$1,043.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312788 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26735 "$1,633.00 " 960 "$1,143.10 " $816.50 "$1,306.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312796 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26740 $611.00 960 $427.70 $305.50 $488.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312812 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26746 "$2,029.00 " 960 "$1,420.30 " "$1,014.50 " "$1,623.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312820 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26750 $523.00 960 $366.10 $261.50 $418.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312838 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26755 $766.00 960 $536.20 $383.00 $612.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312853 PHYSICIAN FEE - SURGERY PF-TREAT FINGER FRACTURE EACH EACH 26765 "$1,381.00 " 960 $966.70 $690.50 "$1,104.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318215 PHYSICIAN FEE - SURGERY PF-TREAT FOOT DISLOCATION EACH 28546 $965.00 960 $675.50 $482.50 $772.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309776 PHYSICIAN FEE - SURGERY PF-TREAT FOREARM BONE LESION EACH 25035 "$1,629.00 " 960 "$1,140.30 " $814.50 "$1,303.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310824 PHYSICIAN FEE - SURGERY PF-TREAT FRACT RADIUS & ULNA EACH 25565 "$1,298.00 " 960 $908.60 $649.00 "$1,038.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310832 PHYSICIAN FEE - SURGERY PF-TREAT FRACT RADIUS & ULNA EACH 25574 "$1,859.00 " 960 "$1,301.30 " $929.50 "$1,487.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310998 PHYSICIAN FEE - SURGERY PF-TREAT FRACT ULNAR STYLOID EACH 25652 "$1,716.00 " 960 "$1,201.20 " $858.00 "$1,372.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310725 PHYSICIAN FEE - SURGERY PF-TREAT FRACTURE OF RADIUS EACH 25500 $717.00 960 $501.90 $358.50 $573.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310733 PHYSICIAN FEE - SURGERY PF-TREAT FRACTURE OF RADIUS EACH 25505 "$1,285.00 " 960 $899.50 $642.50 "$1,028.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310741 PHYSICIAN FEE - SURGERY PF-TREAT FRACTURE OF RADIUS EACH 25515 "$1,847.00 " 960 "$1,292.90 " $923.50 "$1,477.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310766 PHYSICIAN FEE - SURGERY PF-TREAT FRACTURE OF RADIUS EACH 25525 "$2,174.00 " 960 "$1,521.80 " "$1,087.00 " "$1,739.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310774 PHYSICIAN FEE - SURGERY PF-TREAT FRACTURE OF RADIUS EACH 25526 "$2,637.00 " 960 "$1,845.90 " "$1,318.50 " "$2,109.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310790 PHYSICIAN FEE - SURGERY PF-TREAT FRACTURE OF ULNA EACH 25535 "$1,270.00 " 960 $889.00 $635.00 "$1,016.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310808 PHYSICIAN FEE - SURGERY PF-TREAT FRACTURE OF ULNA EACH 25545 "$1,718.00 " 960 "$1,202.60 " $859.00 "$1,374.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310840 PHYSICIAN FEE - SURGERY PF-TREAT FRACTURE RADIUS/ULNA EACH 25575 "$2,486.00 " 960 "$1,740.20 " "$1,243.00 " "$1,988.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310865 PHYSICIAN FEE - SURGERY PF-TREAT FRACTURE RADIUS/ULNA EACH 25605 "$1,421.00 " 960 $994.70 $710.50 "$1,136.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310873 PHYSICIAN FEE - SURGERY PF-TREAT FX DISTAL RADIAL EACH 25606 "$1,842.00 " 960 "$1,289.40 " $921.00 "$1,473.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310881 PHYSICIAN FEE - SURGERY PF-TREAT FX RAD EXTRA-ARTICUL EACH 25607 "$2,033.00 " 960 "$1,423.10 " "$1,016.50 " "$1,626.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310899 PHYSICIAN FEE - SURGERY PF-TREAT FX RAD INTRA-ARTICUL EACH 25608 "$2,276.00 " 960 "$1,593.20 " "$1,138.00 " "$1,820.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310907 PHYSICIAN FEE - SURGERY PF-TREAT FX RADIAL 3+ FRAG EACH 25609 "$2,884.00 " 960 "$2,018.80 " "$1,442.00 " "$2,307.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311319 PHYSICIAN FEE - SURGERY PF-TREAT HAND BONE LESION EACH 26034 "$1,508.00 " 960 "$1,055.60 " $754.00 "$1,206.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312671 PHYSICIAN FEE - SURGERY PF-TREAT HAND DISLOCATION EACH 26675 "$1,176.00 " 960 $823.20 $588.00 $940.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312697 PHYSICIAN FEE - SURGERY PF-TREAT HAND DISLOCATION EACH 26685 "$1,569.00 " 960 "$1,098.30 " $784.50 "$1,255.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312705 PHYSICIAN FEE - SURGERY PF-TREAT HAND DISLOCATION EACH 26686 "$1,719.00 " 960 "$1,203.30 " $859.50 "$1,375.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317951 PHYSICIAN FEE - SURGERY PF-TREAT HEEL FRACTURE EACH 28415 "$3,034.00 " 960 "$2,123.80 " "$1,517.00 " "$2,427.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314032 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27250 $510.00 960 $357.00 $255.00 $408.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314057 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27253 "$2,588.00 " 960 "$1,811.60 " "$1,294.00 " "$2,070.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314040 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27252 "$2,071.00 " 960 "$1,449.70 " "$1,035.50 " "$1,656.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314065 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27254 "$3,502.00 " 960 "$2,451.40 " "$1,751.00 " "$2,801.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314073 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27256 $679.00 960 $475.30 $339.50 $543.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314081 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27257 "$1,000.00 " 960 $700.00 $500.00 $800.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314099 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27258 "$3,063.00 " 960 "$2,144.10 " "$1,531.50 " "$2,450.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314107 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27259 "$4,247.00 " 960 "$2,972.90 " "$2,123.50 " "$3,397.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314115 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27265 "$1,164.00 " 960 $814.80 $582.00 $931.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314123 PHYSICIAN FEE - SURGERY PF-TREAT HIP DISLOCATION EACH 27266 "$1,610.00 " 960 "$1,127.00 " $805.00 "$1,288.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313919 PHYSICIAN FEE - SURGERY PF-TREAT HIP FRACTURE(S) EACH 27227 "$4,544.00 " 960 "$3,180.80 " "$2,272.00 " "$3,635.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313927 PHYSICIAN FEE - SURGERY PF-TREAT HIP FRACTURE(S) EACH 27228 "$5,171.00 " 960 "$3,619.70 " "$2,585.50 " "$4,136.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313885 PHYSICIAN FEE - SURGERY PF-TREAT HIP SOCKET FRACTURE EACH 27220 "$1,144.00 " 960 $800.80 $572.00 $915.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313893 PHYSICIAN FEE - SURGERY PF-TREAT HIP SOCKET FRACTURE EACH 27222 "$2,698.00 " 960 "$1,888.60 " "$1,349.00 " "$2,158.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313901 PHYSICIAN FEE - SURGERY PF-TREAT HIP WALL FRACTURE EACH 27226 "$2,916.00 " 960 "$2,041.20 " "$1,458.00 " "$2,332.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308406 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 23625 $986.00 960 $690.20 $493.00 $788.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309313 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24516 "$2,366.00 " 960 "$1,656.20 " "$1,183.00 " "$1,892.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308356 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 23600 $875.00 960 $612.50 $437.50 $700.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308364 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 23605 "$1,190.00 " 960 $833.00 $595.00 $952.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308372 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 23615 "$2,429.00 " 960 "$1,700.30 " "$1,214.50 " "$1,943.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308380 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 23616 "$3,404.00 " 960 "$2,382.80 " "$1,702.00 " "$2,723.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308398 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 23620 $720.00 960 $504.00 $360.00 $576.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308414 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 23630 "$2,149.00 " 960 "$1,504.30 " "$1,074.50 " "$1,719.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309289 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24500 $930.00 960 $651.00 $465.00 $744.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309297 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24505 "$1,260.00 " 960 $882.00 $630.00 "$1,008.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309305 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24515 "$2,421.00 " 960 "$1,694.70 " "$1,210.50 " "$1,936.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309321 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24530 $976.00 960 $683.20 $488.00 $780.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309339 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24535 "$1,591.00 " 960 "$1,113.70 " $795.50 "$1,272.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309347 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24538 "$2,166.00 " 960 "$1,516.20 " "$1,083.00 " "$1,732.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309354 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24545 "$2,556.00 " 960 "$1,789.20 " "$1,278.00 " "$2,044.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309362 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24546 "$2,851.00 " 960 "$1,995.70 " "$1,425.50 " "$2,280.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309370 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24560 $818.00 960 $572.60 $409.00 $654.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309388 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24565 "$1,376.00 " 960 $963.20 $688.00 "$1,100.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309396 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24566 "$1,985.00 " 960 "$1,389.50 " $992.50 "$1,588.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309404 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24575 "$2,016.00 " 960 "$1,411.20 " "$1,008.00 " "$1,612.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309412 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24576 $871.00 960 $609.70 $435.50 $696.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309420 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24577 "$1,410.00 " 960 $987.00 $705.00 "$1,128.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309438 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24579 "$2,295.00 " 960 "$1,606.50 " "$1,147.50 " "$1,836.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309446 PHYSICIAN FEE - SURGERY PF-TREAT HUMERUS FRACTURE EACH 24582 "$2,245.00 " 960 "$1,571.50 " "$1,122.50 " "$1,796.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315419 PHYSICIAN FEE - SURGERY PF-TREAT KNEE DISLOCATION EACH 27550 "$1,308.00 " 960 $915.60 $654.00 "$1,046.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315427 PHYSICIAN FEE - SURGERY PF-TREAT KNEE DISLOCATION EACH 27552 "$1,751.00 " 960 "$1,225.70 " $875.50 "$1,400.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315435 PHYSICIAN FEE - SURGERY PF-TREAT KNEE DISLOCATION EACH 27556 "$2,416.00 " 960 "$1,691.20 " "$1,208.00 " "$1,932.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315443 PHYSICIAN FEE - SURGERY PF-TREAT KNEE DISLOCATION EACH 27557 "$2,880.00 " 960 "$2,016.00 " "$1,440.00 " "$2,304.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315450 PHYSICIAN FEE - SURGERY PF-TREAT KNEE DISLOCATION EACH 27558 "$3,276.00 " 960 "$2,293.20 " "$1,638.00 " "$2,620.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315351 PHYSICIAN FEE - SURGERY PF-TREAT KNEE FRACTURE EACH 27530 $798.00 960 $558.60 $399.00 $638.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315369 PHYSICIAN FEE - SURGERY PF-TREAT KNEE FRACTURE EACH 27532 "$1,606.00 " 960 "$1,124.20 " $803.00 "$1,284.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315377 PHYSICIAN FEE - SURGERY PF-TREAT KNEE FRACTURE EACH 27535 "$2,471.00 " 960 "$1,729.70 " "$1,235.50 " "$1,976.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315385 PHYSICIAN FEE - SURGERY PF-TREAT KNEE FRACTURE EACH 27536 "$3,270.00 " 960 "$2,289.00 " "$1,635.00 " "$2,616.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315401 PHYSICIAN FEE - SURGERY PF-TREAT KNEE FRACTURE EACH 27540 "$2,241.00 " 960 "$1,568.70 " "$1,120.50 " "$1,792.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315393 PHYSICIAN FEE - SURGERY PF-TREAT KNEE FRACTURE(S) EACH 27538 "$1,245.00 " 960 $871.50 $622.50 $996.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315476 PHYSICIAN FEE - SURGERY PF-TREAT KNEECAP DISLOCATION EACH 27562 "$1,357.00 " 960 $949.90 $678.50 "$1,085.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315484 PHYSICIAN FEE - SURGERY PF-TREAT KNEECAP DISLOCATION EACH 27566 "$2,464.00 " 960 "$1,724.80 " "$1,232.00 " "$1,971.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315336 PHYSICIAN FEE - SURGERY PF-TREAT KNEECAP FRACTURE EACH 27520 $834.00 960 $583.80 $417.00 $667.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315344 PHYSICIAN FEE - SURGERY PF-TREAT KNEECAP FRACTURE EACH 27524 "$2,076.00 " 960 "$1,453.20 " "$1,038.00 " "$1,660.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312713 PHYSICIAN FEE - SURGERY PF-TREAT KNUCKLE DISLOCATION EACH 26700 $878.00 960 $614.60 $439.00 $702.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312721 PHYSICIAN FEE - SURGERY PF-TREAT KNUCKLE DISLOCATION EACH 26705 "$1,103.00 " 960 $772.10 $551.50 $882.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312747 PHYSICIAN FEE - SURGERY PF-TREAT KNUCKLE DISLOCATION EACH 26715 "$1,573.00 " 960 "$1,101.10 " $786.50 "$1,258.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321201 PHYSICIAN FEE - SURGERY PF-TREAT LARYNX FRACTURE EACH 31584 "$3,742.00 " 960 "$2,619.40 " "$1,871.00 " "$2,993.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306160 PHYSICIAN FEE - SURGERY PF-TREAT LOWER JAW FRACTURE EACH 21450 "$1,233.00 " 960 $863.10 $616.50 $986.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306178 PHYSICIAN FEE - SURGERY PF-TREAT LOWER JAW FRACTURE EACH 21451 "$1,647.00 " 960 "$1,152.90 " $823.50 "$1,317.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306186 PHYSICIAN FEE - SURGERY PF-TREAT LOWER JAW FRACTURE EACH 21452 "$1,168.00 " 960 $817.60 $584.00 $934.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306194 PHYSICIAN FEE - SURGERY PF-TREAT LOWER JAW FRACTURE EACH 21453 "$2,405.00 " 960 "$1,683.50 " "$1,202.50 " "$1,924.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306202 PHYSICIAN FEE - SURGERY PF-TREAT LOWER JAW FRACTURE EACH 21454 "$1,281.00 " 960 $896.70 $640.50 "$1,024.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306210 PHYSICIAN FEE - SURGERY PF-TREAT LOWER JAW FRACTURE EACH 21461 "$2,766.00 " 960 "$1,936.20 " "$1,383.00 " "$2,212.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306228 PHYSICIAN FEE - SURGERY PF-TREAT LOWER JAW FRACTURE EACH 21462 "$3,018.00 " 960 "$2,112.60 " "$1,509.00 " "$2,414.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306236 PHYSICIAN FEE - SURGERY PF-TREAT LOWER JAW FRACTURE EACH 21465 "$2,090.00 " 960 "$1,463.00 " "$1,045.00 " "$1,672.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306244 PHYSICIAN FEE - SURGERY PF-TREAT LOWER JAW FRACTURE EACH 21470 "$3,101.00 " 960 "$2,170.70 " "$1,550.50 " "$2,480.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315641 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG BONE LESION EACH 27607 "$1,635.00 " 960 "$1,144.50 " $817.50 "$1,308.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316607 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG DISLOCATION EACH 27830 "$1,000.00 " 960 $700.00 $500.00 $800.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316615 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG DISLOCATION EACH 27831 "$1,133.00 " 960 $793.10 $566.50 $906.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316623 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG DISLOCATION EACH 27832 "$2,091.00 " 960 "$1,463.70 " "$1,045.50 " "$1,672.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316540 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG FRACTURE EACH 27824 $842.00 960 $589.40 $421.00 $673.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316557 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG FRACTURE EACH 27825 "$1,366.00 " 960 $956.20 $683.00 "$1,092.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316565 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG FRACTURE EACH 27826 "$1,989.00 " 960 "$1,392.30 " $994.50 "$1,591.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316573 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG FRACTURE EACH 27827 "$3,055.00 " 960 "$2,138.50 " "$1,527.50 " "$2,444.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316581 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG FRACTURE EACH 27828 "$3,625.00 " 960 "$2,537.50 " "$1,812.50 " "$2,900.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316599 PHYSICIAN FEE - SURGERY PF-TREAT LOWER LEG JOINT EACH 27829 "$1,921.00 " 960 "$1,344.70 " $960.50 "$1,536.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312580 PHYSICIAN FEE - SURGERY PF-TREAT METACARPAL FRACTURE EACH 26605 $825.00 960 $577.50 $412.50 $660.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312598 PHYSICIAN FEE - SURGERY PF-TREAT METACARPAL FRACTURE EACH 26607 "$1,392.00 " 960 $974.40 $696.00 "$1,113.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312606 PHYSICIAN FEE - SURGERY PF-TREAT METACARPAL FRACTURE EACH 26608 "$1,325.00 " 960 $927.50 $662.50 "$1,060.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312614 PHYSICIAN FEE - SURGERY PF-TREAT METACARPAL FRACTURE EACH 26615 "$1,578.00 " 960 "$1,104.60 " $789.00 "$1,262.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318025 PHYSICIAN FEE - SURGERY PF-TREAT MIDFOOT FRACTURE EACH EACH 28450 $517.00 960 $361.90 $258.50 $413.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306079 PHYSICIAN FEE - SURGERY PF-TREAT MOUTH ROOF FRACTURE EACH 21422 "$1,658.00 " 960 "$1,160.60 " $829.00 "$1,326.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306087 PHYSICIAN FEE - SURGERY PF-TREAT MOUTH ROOF FRACTURE EACH 21423 "$2,156.00 " 960 "$1,509.20 " "$1,078.00 " "$1,724.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305808 PHYSICIAN FEE - SURGERY PF-TREAT NASAL SEPTAL FRACTURE EACH 21336 "$1,683.00 " 960 "$1,178.10 " $841.50 "$1,346.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305816 PHYSICIAN FEE - SURGERY PF-TREAT NASAL SEPTAL FRACTURE EACH 21337 $804.00 960 $562.80 $402.00 $643.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305824 PHYSICIAN FEE - SURGERY PF-TREAT NASOETHMOID FRACTURE EACH 21338 "$1,770.00 " 960 "$1,239.00 " $885.00 "$1,416.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305832 PHYSICIAN FEE - SURGERY PF-TREAT NASOETHMOID FRACTURE EACH 21339 "$2,004.00 " 960 "$1,402.80 " "$1,002.00 " "$1,603.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306947 PHYSICIAN FEE - SURGERY PF-TREAT NECK SPINE FRACTURE EACH 22326 "$4,433.00 " 960 "$3,103.10 " "$2,216.50 " "$3,546.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305873 PHYSICIAN FEE - SURGERY PF-TREAT NOSE/JAW FRACTURE EACH 21345 "$1,721.00 " 960 "$1,204.70 " $860.50 "$1,376.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305881 PHYSICIAN FEE - SURGERY PF-TREAT NOSE/JAW FRACTURE EACH 21346 "$2,695.00 " 960 "$1,886.50 " "$1,347.50 " "$2,156.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305899 PHYSICIAN FEE - SURGERY PF-TREAT NOSE/JAW FRACTURE EACH 21347 "$2,757.00 " 960 "$1,929.90 " "$1,378.50 " "$2,205.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305907 PHYSICIAN FEE - SURGERY PF-TREAT NOSE/JAW FRACTURE EACH 21348 "$2,945.00 " 960 "$2,061.50 " "$1,472.50 " "$2,356.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306921 PHYSICIAN FEE - SURGERY PF-TREAT ODONTOID FX W/GRAFT EACH 22319 "$5,510.00 " 960 "$3,857.00 " "$2,755.00 " "$4,408.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306913 PHYSICIAN FEE - SURGERY PF-TREAT ODONTOID FX W/O GRAFT EACH 22318 "$4,934.00 " 960 "$3,453.80 " "$2,467.00 " "$3,947.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313844 PHYSICIAN FEE - SURGERY PF-TREAT PELVIC FRACTURE EACH 27215 "$1,598.00 " 960 "$1,118.60 " $799.00 "$1,278.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313869 PHYSICIAN FEE - SURGERY PF-TREAT PELVIC RING FRACTURE EACH 27217 "$2,218.00 " 960 "$1,552.60 " "$1,109.00 " "$1,774.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313877 PHYSICIAN FEE - SURGERY PF-TREAT PELVIC RING FRACTURE EACH 27218 "$3,045.00 " 960 "$2,131.50 " "$1,522.50 " "$2,436.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341381 PHYSICIAN FEE - SURGERY PF-TREAT PENIS LESION GRAFT EACH 54111 "$2,121.00 " 960 "$1,484.70 " "$1,060.50 " "$1,696.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341399 PHYSICIAN FEE - SURGERY PF-TREAT PENIS LESION GRAFT EACH 54112 "$2,487.00 " 960 "$1,740.90 " "$1,243.50 " "$1,989.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322290 PHYSICIAN FEE - SURGERY PF-TREAT PLEURODESIS W/AGENT EACH 32560 $206.00 960 $144.20 $103.00 $164.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309537 PHYSICIAN FEE - SURGERY PF-TREAT RADIUS FRACTURE EACH 24650 $682.00 960 $477.40 $341.00 $545.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309545 PHYSICIAN FEE - SURGERY PF-TREAT RADIUS FRACTURE EACH 24655 "$1,132.00 " 960 $792.40 $566.00 $905.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309552 PHYSICIAN FEE - SURGERY PF-TREAT RADIUS FRACTURE EACH 24665 "$1,805.00 " 960 "$1,263.50 " $902.50 "$1,444.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309560 PHYSICIAN FEE - SURGERY PF-TREAT RADIUS FRACTURE EACH 24666 "$2,014.00 " 960 "$1,409.80 " "$1,007.00 " "$1,611.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308349 PHYSICIAN FEE - SURGERY PF-TREAT SCAPULA FRACTURE EACH 23585 "$2,680.00 " 960 "$1,876.00 " "$1,340.00 " "$2,144.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308323 PHYSICIAN FEE - SURGERY PF-TREAT SHOULDER BLADE FX EACH 23570 $654.00 960 $457.80 $327.00 $523.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308331 PHYSICIAN FEE - SURGERY PF-TREAT SHOULDER BLADE FX EACH 23575 "$1,056.00 " 960 $739.20 $528.00 $844.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308422 PHYSICIAN FEE - SURGERY PF-TREAT SHOULDER DISLOCATION EACH 23650 $843.00 960 $590.10 $421.50 $674.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308430 PHYSICIAN FEE - SURGERY PF-TREAT SHOULDER DISLOCATION EACH 23655 "$1,128.00 " 960 $789.60 $564.00 $902.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98308448 PHYSICIAN FEE - SURGERY PF-TREAT SHOULDER DISLOCATION EACH 23660 "$1,613.00 " 960 "$1,129.10 " $806.50 "$1,290.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347354 PHYSICIAN FEE - SURGERY PF-TREAT SKULL FRACTURE EACH 62000 "$3,107.00 " 960 "$2,174.90 " "$1,553.50 " "$2,485.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347362 PHYSICIAN FEE - SURGERY PF-TREAT SKULL FRACTURE EACH 62005 "$3,835.00 " 960 "$2,684.50 " "$1,917.50 " "$3,068.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313729 PHYSICIAN FEE - SURGERY PF-TREAT SLIPPED EPIPHYSIS EACH 27175 "$1,842.00 " 960 "$1,289.40 " $921.00 "$1,473.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313737 PHYSICIAN FEE - SURGERY PF-TREAT SLIPPED EPIPHYSIS EACH 27176 "$2,541.00 " 960 "$1,778.70 " "$1,270.50 " "$2,032.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313745 PHYSICIAN FEE - SURGERY PF-TREAT SLIPPED EPIPHYSIS EACH 27177 "$3,074.00 " 960 "$2,151.80 " "$1,537.00 " "$2,459.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313752 PHYSICIAN FEE - SURGERY PF-TREAT SLIPPED EPIPHYSIS EACH 27178 "$2,541.00 " 960 "$1,778.70 " "$1,270.50 " "$2,032.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313778 PHYSICIAN FEE - SURGERY PF-TREAT SLIPPED EPIPHYSIS EACH 27181 "$3,087.00 " 960 "$2,160.90 " "$1,543.50 " "$2,469.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347784 PHYSICIAN FEE - SURGERY PF-TREAT SPINAL CORD LESION EACH 62280 $419.00 960 $293.30 $209.50 $335.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306897 PHYSICIAN FEE - SURGERY PF-TREAT SPINE FRACTURE EACH 22310 $821.00 960 $574.70 $410.50 $656.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306905 PHYSICIAN FEE - SURGERY PF-TREAT SPINE FRACTURE EACH 22315 "$2,172.00 " 960 "$1,520.40 " "$1,086.00 " "$1,737.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306939 PHYSICIAN FEE - SURGERY PF-TREAT SPINE FRACTURE EACH 22325 "$4,293.00 " 960 "$3,005.10 " "$2,146.50 " "$3,434.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306574 PHYSICIAN FEE - SURGERY PF-TREAT STERNUM FRACTURE EACH 21820 $408.00 960 $285.60 $204.00 $326.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306582 PHYSICIAN FEE - SURGERY PF-TREAT STERNUM FRACTURE EACH 21825 "$1,535.00 " 960 "$1,074.50 " $767.50 "$1,228.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313828 PHYSICIAN FEE - SURGERY PF-TREAT TAIL BONE FRACTURE EACH 27200 $524.00 960 $366.80 $262.00 $419.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313836 PHYSICIAN FEE - SURGERY PF-TREAT TAIL BONE FRACTURE EACH 27202 "$1,460.00 " 960 "$1,022.00 " $730.00 "$1,168.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313935 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27230 "$1,325.00 " 960 $927.50 $662.50 "$1,060.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313943 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27232 "$2,019.00 " 960 "$1,413.30 " "$1,009.50 " "$1,615.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313950 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27235 "$2,496.00 " 960 "$1,747.20 " "$1,248.00 " "$1,996.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313968 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27236 "$3,285.00 " 960 "$2,299.50 " "$1,642.50 " "$2,628.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313976 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27238 "$1,295.00 " 960 $906.50 $647.50 "$1,036.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313984 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27240 "$2,625.00 " 960 "$1,837.50 " "$1,312.50 " "$2,100.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98313992 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27244 "$3,378.00 " 960 "$2,364.60 " "$1,689.00 " "$2,702.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314008 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27245 "$3,372.00 " 960 "$2,360.40 " "$1,686.00 " "$2,697.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314016 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27246 "$1,073.00 " 960 $751.10 $536.50 $858.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98314024 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FRACTURE EACH 27248 "$2,054.00 " 960 "$1,437.80 " "$1,027.00 " "$1,643.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315310 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FX GROWTH PLATE EACH 27517 "$1,904.00 " 960 "$1,332.80 " $952.00 "$1,523.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315302 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FX GROWTH PLATE EACH 27516 "$1,345.00 " 960 $941.50 $672.50 "$1,076.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315328 PHYSICIAN FEE - SURGERY PF-TREAT THIGH FX GROWTH PLATE EACH 27519 "$2,454.00 " 960 "$1,717.80 " "$1,227.00 " "$1,963.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98306954 PHYSICIAN FEE - SURGERY PF-TREAT THORAX SPINE FRACTURE EACH 22327 "$4,489.00 " 960 "$3,142.30 " "$2,244.50 " "$3,591.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312622 PHYSICIAN FEE - SURGERY PF-TREAT THUMB DISLOCATION EACH 26641 "$1,063.00 " 960 $744.10 $531.50 $850.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312630 PHYSICIAN FEE - SURGERY PF-TREAT THUMB FRACTURE EACH 26645 "$1,101.00 " 960 $770.70 $550.50 $880.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312648 PHYSICIAN FEE - SURGERY PF-TREAT THUMB FRACTURE EACH 26650 "$1,320.00 " 960 $924.00 $660.00 "$1,056.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98312655 PHYSICIAN FEE - SURGERY PF-TREAT THUMB FRACTURE EACH 26665 "$1,705.00 " 960 "$1,193.50 " $852.50 "$1,364.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347172 PHYSICIAN FEE - SURGERY PF-TREAT TRIGEMINAL NERVE EACH 61790 "$2,630.00 " 960 "$1,841.00 " "$1,315.00 " "$2,104.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347180 PHYSICIAN FEE - SURGERY PF-TREAT TRIGEMINAL TRACT EACH 61791 "$3,390.00 " 960 "$2,373.00 " "$1,695.00 " "$2,712.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309578 PHYSICIAN FEE - SURGERY PF-TREAT ULNAR FRACTURE EACH 24670 $744.00 960 $520.80 $372.00 $595.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309586 PHYSICIAN FEE - SURGERY PF-TREAT ULNAR FRACTURE EACH 24675 "$1,161.00 " 960 $812.70 $580.50 $928.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98309594 PHYSICIAN FEE - SURGERY PF-TREAT ULNAR FRACTURE EACH 24685 "$1,798.00 " 960 "$1,258.60 " $899.00 "$1,438.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345341 PHYSICIAN FEE - SURGERY PF-TREAT UTERUS INFECTION EACH 59830 "$1,338.00 " 960 $936.60 $669.00 "$1,070.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310931 PHYSICIAN FEE - SURGERY PF-TREAT WRIST BONE FRACTURE EACH 25628 "$1,970.00 " 960 "$1,379.00 " $985.00 "$1,576.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310972 PHYSICIAN FEE - SURGERY PF-TREAT WRIST BONE FRACTURE EACH 25650 $850.00 960 $595.00 $425.00 $680.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310923 PHYSICIAN FEE - SURGERY PF-TREAT WRIST BONE FRACTURE EACH 25624 "$1,236.00 " 960 $865.20 $618.00 $988.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310949 PHYSICIAN FEE - SURGERY PF-TREAT WRIST BONE FRACTURE EACH 25630 $790.00 960 $553.00 $395.00 $632.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310956 PHYSICIAN FEE - SURGERY PF-TREAT WRIST BONE FRACTURE EACH 25635 "$1,176.00 " 960 $823.20 $588.00 $940.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310964 PHYSICIAN FEE - SURGERY PF-TREAT WRIST BONE FRACTURE EACH 25645 "$1,580.00 " 960 "$1,106.00 " $790.00 "$1,264.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311004 PHYSICIAN FEE - SURGERY PF-TREAT WRIST DISLOCATION EACH 25660 "$1,245.00 " 960 $871.50 $622.50 $996.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311012 PHYSICIAN FEE - SURGERY PF-TREAT WRIST DISLOCATION EACH 25670 "$1,674.00 " 960 "$1,171.80 " $837.00 "$1,339.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311038 PHYSICIAN FEE - SURGERY PF-TREAT WRIST DISLOCATION EACH 25675 "$1,154.00 " 960 $807.80 $577.00 $923.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311046 PHYSICIAN FEE - SURGERY PF-TREAT WRIST DISLOCATION EACH 25676 "$1,734.00 " 960 "$1,213.80 " $867.00 "$1,387.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311079 PHYSICIAN FEE - SURGERY PF-TREAT WRIST DISLOCATION EACH 25690 "$1,365.00 " 960 $955.50 $682.50 "$1,092.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311087 PHYSICIAN FEE - SURGERY PF-TREAT WRIST DISLOCATION EACH 25695 "$1,754.00 " 960 "$1,227.80 " $877.00 "$1,403.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311053 PHYSICIAN FEE - SURGERY PF-TREAT WRIST FRACTURE EACH 25680 "$1,467.00 " 960 "$1,026.90 " $733.50 "$1,173.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98311061 PHYSICIAN FEE - SURGERY PF-TREAT WRIST FRACTURE EACH 25685 "$2,032.00 " 960 "$1,422.40 " "$1,016.00 " "$1,625.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317969 PHYSICIAN FEE - SURGERY PF-TREAT/GRAFT HEEL FRACTURE EACH 28420 "$3,554.00 " 960 "$2,487.80 " "$1,777.00 " "$2,843.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330962 PHYSICIAN FEE - SURGERY PF-TREATMENT MOUTH ROOF LESION EACH 42160 $374.00 960 $261.80 $187.00 $299.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336050 PHYSICIAN FEE - SURGERY PF-TREATMENT OF ANAL FISSURE EACH 46942 $350.00 960 $245.00 $175.00 $280.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336043 PHYSICIAN FEE - SURGERY PF-TREATMENT OF ANAL FISSURE EACH 46940 $390.00 960 $273.00 $195.00 $312.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316458 PHYSICIAN FEE - SURGERY PF-TREATMENT OF ANKLE FRACTURE EACH 27788 "$1,069.00 " 960 $748.30 $534.50 $855.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316482 PHYSICIAN FEE - SURGERY PF-TREATMENT OF ANKLE FRACTURE EACH 27810 "$1,194.00 " 960 $835.80 $597.00 $955.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316516 PHYSICIAN FEE - SURGERY PF-TREATMENT OF ANKLE FRACTURE EACH 27818 "$1,230.00 " 960 $861.00 $615.00 $984.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316524 PHYSICIAN FEE - SURGERY PF-TREATMENT OF ANKLE FRACTURE EACH 27822 "$2,378.00 " 960 "$1,664.60 " "$1,189.00 " "$1,902.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316532 PHYSICIAN FEE - SURGERY PF-TREATMENT OF ANKLE FRACTURE EACH 27823 "$2,687.00 " 960 "$1,880.90 " "$1,343.50 " "$2,149.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304215 PHYSICIAN FEE - SURGERY PF-TREATMENT OF BONE CYST EACH 20615 $434.00 960 $303.80 $217.00 $347.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352248 PHYSICIAN FEE - SURGERY PF-TREATMENT OF CHOROID LESION EACH 67220 "$1,272.00 " 960 $890.40 $636.00 "$1,017.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316813 PHYSICIAN FEE - SURGERY PF-TREATMENT OF FOOT INFECTION EACH 28002 $368.00 960 $257.60 $184.00 $294.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360431 PHYSICIAN FEE - SURGERY PF-TREATMENT OF GUM LESION EACH 41850 $200.00 960 $140.00 $100.00 $160.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347370 PHYSICIAN FEE - SURGERY PF-TREATMENT OF HEAD INJURY EACH 62010 "$4,632.00 " 960 "$3,242.40 " "$2,316.00 " "$3,705.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345317 PHYSICIAN FEE - SURGERY PF-TREATMENT OF MISCARRIAGE EACH 59812 $888.00 960 $621.60 $444.00 $710.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345333 PHYSICIAN FEE - SURGERY PF-TREATMENT OF MISCARRIAGE EACH 59821 "$1,084.00 " 960 $758.80 $542.00 $867.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98330319 PHYSICIAN FEE - SURGERY PF-TREATMENT OF MOUTH LESION EACH 40820 $430.00 960 $301.00 $215.00 $344.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305758 PHYSICIAN FEE - SURGERY PF-TREATMENT OF NOSE FRACTURE EACH 21315 $162.00 960 $113.40 $81.00 $129.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305766 PHYSICIAN FEE - SURGERY PF-TREATMENT OF NOSE FRACTURE EACH 21320 $257.00 960 $179.90 $128.50 $205.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305774 PHYSICIAN FEE - SURGERY PF-TREATMENT OF NOSE FRACTURE EACH 21325 "$1,170.00 " 960 $819.00 $585.00 $936.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305782 PHYSICIAN FEE - SURGERY PF-TREATMENT OF NOSE FRACTURE EACH 21330 "$1,415.00 " 960 $990.50 $707.50 "$1,132.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305790 PHYSICIAN FEE - SURGERY PF-TREATMENT OF NOSE FRACTURE EACH 21335 "$1,912.00 " 960 "$1,338.40 " $956.00 "$1,529.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305840 PHYSICIAN FEE - SURGERY PF-TREATMENT OF NOSE FRACTURE EACH 21340 "$2,026.00 " 960 "$1,418.20 " "$1,013.00 " "$1,620.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341373 PHYSICIAN FEE - SURGERY PF-TREATMENT OF PENIS LESION EACH 54110 "$1,661.00 " 960 "$1,162.70 " $830.50 "$1,328.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341407 PHYSICIAN FEE - SURGERY PF-TREATMENT OF PENIS LESION EACH 54115 "$1,137.00 " 960 $795.90 $568.50 $909.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341514 PHYSICIAN FEE - SURGERY PF-TREATMENT OF PENIS LESION EACH 54200 $232.00 960 $162.40 $116.00 $185.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341522 PHYSICIAN FEE - SURGERY PF-TREATMENT OF PENIS LESION EACH 54205 "$1,418.00 " 960 $992.60 $709.00 "$1,134.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341530 PHYSICIAN FEE - SURGERY PF-TREATMENT OF PENIS LESION EACH 54220 $367.00 960 $256.90 $183.50 $293.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352230 PHYSICIAN FEE - SURGERY PF-TREATMENT OF RETINAL LESION EACH 67218 "$3,549.00 " 960 "$2,484.30 " "$1,774.50 " "$2,839.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352271 PHYSICIAN FEE - SURGERY PF-TREATMENT OF RETINAL LESION EACH 67227 $650.00 960 $455.00 $325.00 $520.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354491 PHYSICIAN FEE - SURGERY PF-TREATMENT OF RIB FRACTURE EACH 21812 "$2,020.00 " 960 "$1,414.00 " "$1,010.00 " "$1,616.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98354509 PHYSICIAN FEE - SURGERY PF-TREATMENT OF RIB FRACTURE EACH 21813 "$2,791.00 " 960 "$1,953.70 " "$1,395.50 " "$2,232.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305857 PHYSICIAN FEE - SURGERY PF-TREATMENT OF SINUS FRACTURE EACH 21343 "$2,895.00 " 960 "$2,026.50 " "$1,447.50 " "$2,316.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98305865 PHYSICIAN FEE - SURGERY PF-TREATMENT OF SINUS FRACTURE EACH 21344 "$3,733.00 " 960 "$2,613.10 " "$1,866.50 " "$2,986.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315237 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27507 "$2,665.00 " 960 "$1,865.50 " "$1,332.50 " "$2,132.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315187 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27500 "$1,332.00 " 960 $932.40 $666.00 "$1,065.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315195 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27501 "$1,376.00 " 960 $963.20 $688.00 "$1,100.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315203 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27502 "$2,090.00 " 960 "$1,463.00 " "$1,045.00 " "$1,672.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315211 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27503 "$2,205.00 " 960 "$1,543.50 " "$1,102.50 " "$1,764.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315229 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27506 "$3,680.00 " 960 "$2,576.00 " "$1,840.00 " "$2,944.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315245 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27508 "$1,378.00 " 960 $964.60 $689.00 "$1,102.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315252 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27509 "$1,846.00 " 960 "$1,292.20 " $923.00 "$1,476.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315260 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27510 "$1,891.00 " 960 "$1,323.70 " $945.50 "$1,512.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315278 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27511 "$2,745.00 " 960 "$1,921.50 " "$1,372.50 " "$2,196.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315286 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27513 "$3,402.00 " 960 "$2,381.40 " "$1,701.00 " "$2,721.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98315294 PHYSICIAN FEE - SURGERY PF-TREATMENT OF THIGH FRACTURE EACH 27514 "$2,659.00 " 960 "$1,861.30 " "$1,329.50 " "$2,127.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316326 PHYSICIAN FEE - SURGERY PF-TREATMENT OF TIBIA FRACTURE EACH 27756 "$1,586.00 " 960 "$1,110.20 " $793.00 "$1,268.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316300 PHYSICIAN FEE - SURGERY PF-TREATMENT OF TIBIA FRACTURE EACH 27750 $896.00 960 $627.20 $448.00 $716.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316318 PHYSICIAN FEE - SURGERY PF-TREATMENT OF TIBIA FRACTURE EACH 27752 "$1,362.00 " 960 $953.40 $681.00 "$1,089.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316334 PHYSICIAN FEE - SURGERY PF-TREATMENT OF TIBIA FRACTURE EACH 27758 "$2,468.00 " 960 "$1,727.60 " "$1,234.00 " "$1,974.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316342 PHYSICIAN FEE - SURGERY PF-TREATMENT OF TIBIA FRACTURE EACH 27759 "$2,744.00 " 960 "$1,920.80 " "$1,372.00 " "$2,195.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340862 PHYSICIAN FEE - SURGERY PF-TREATMENT OF URETHRA LESION EACH 53260 $486.00 960 $340.20 $243.00 $388.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340813 PHYSICIAN FEE - SURGERY PF-TREATMENT OF URETHRA LESION EACH 53220 "$1,204.00 " 960 $842.80 $602.00 $963.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340870 PHYSICIAN FEE - SURGERY PF-TREATMENT OF URETHRA LESION EACH 53265 $508.00 960 $355.60 $254.00 $406.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98355258 PHYSICIAN FEE - SURGERY PF-TRIM NAIL(S) EACH G0127 $20.00 960 $14.00 $10.00 $16.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300288 PHYSICIAN FEE - SURGERY PF-TRIM SKIN LESION EACH 11055 $41.00 960 $28.70 $20.50 $32.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300296 PHYSICIAN FEE - SURGERY PF-TRIM SKIN LESIONS 2 TO 4 EACH 11056 $58.00 960 $40.60 $29.00 $46.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98300304 PHYSICIAN FEE - SURGERY PF-TRIM SKIN LESIONS OVER 4 EACH 11057 $75.00 960 $52.50 $37.50 $60.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359722 PHYSICIAN FEE - SURGERY PF-TRLUML BAL ANGIOP ADDL VEIN EACH 37249 $395.00 960 $276.50 $197.50 $316.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346703 PHYSICIAN FEE - SURGERY PF-TRNSCOCHLEAR APPROACH/SKULL EACH 61596 "$6,539.00 " 960 "$4,577.30 " "$3,269.50 " "$5,231.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351554 PHYSICIAN FEE - SURGERY PF-TRNSLM DIL EYE CANAL W/STNT EACH 66175 "$1,854.00 " 960 "$1,297.80 " $927.00 "$1,483.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360183 PHYSICIAN FEE - SURGERY PF-TRURL DSTRJ PRST8 TISS RF W EACH 53854 "$1,014.00 " 960 $709.80 $507.00 $811.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345812 PHYSICIAN FEE - SURGERY PF-TWIST DRILL HOLE EACH 61105 "$1,373.00 " 960 $961.10 $686.50 "$1,098.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317985 PHYSICIAN FEE - SURGERY PF-TX ANKLE FRACT CLOSED W/MAP EACH 28435 $909.00 960 $636.30 $454.50 $727.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317993 PHYSICIAN FEE - SURGERY PF-TX ANKLE FRACT PERCUT W/MAP EACH 28436 "$1,354.00 " 960 $947.80 $677.00 "$1,083.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310915 PHYSICIAN FEE - SURGERY PF-TX CARP SCAPH FX; W/O MANIP EACH 25622 $787.00 960 $550.90 $393.50 $629.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318363 PHYSICIAN FEE - SURGERY PF-TX CL INTPHLNGL DISLOC W/AN EACH 28665 $335.00 960 $234.50 $167.50 $268.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318355 PHYSICIAN FEE - SURGERY PF-TX CL INTPHLNGL DISLOC WO A EACH 28660 $260.00 960 $182.00 $130.00 $208.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318314 PHYSICIAN FEE - SURGERY PF-TX CLOSD METAPH DISLOC WO A EACH 28630 $302.00 960 $211.40 $151.00 $241.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318280 PHYSICIAN FEE - SURGERY PF-TX CLOSD TARSMET DISLOC W/A EACH 28605 $840.00 960 $588.00 $420.00 $672.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318207 PHYSICIAN FEE - SURGERY PF-TX CLOSED FOOT DISLOCAT W/A EACH 28545 $747.00 960 $522.90 $373.50 $597.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318322 PHYSICIAN FEE - SURGERY PF-TX CLOSED METAPH DISLOC W/A EACH 28635 $347.00 960 $242.90 $173.50 $277.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318173 PHYSICIAN FEE - SURGERY PF-TX CLOSED SESAMD BONE FRACT EACH 28530 $273.00 960 $191.10 $136.50 $218.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318231 PHYSICIAN FEE - SURGERY PF-TX CLOSED TAL DISLOCAT WO A EACH 28570 $545.00 960 $381.50 $272.50 $436.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318199 PHYSICIAN FEE - SURGERY PF-TX CLOSED TARSL DISLOC WO A EACH 28540 $466.00 960 $326.20 $233.00 $372.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316508 PHYSICIAN FEE - SURGERY PF-TX FX ANKLE TRIMALL W/O MAN EACH 27816 $816.00 960 $571.20 $408.00 $652.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333149 PHYSICIAN FEE - SURGERY PF-TX GASTRO INTUB W/ASP EACH 43753 $60.00 960 $42.00 $30.00 $48.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98317928 PHYSICIAN FEE - SURGERY PF-TX HEEL FRACT CLOSED WO MAN EACH 28400 $626.00 960 $438.20 $313.00 $500.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316425 PHYSICIAN FEE - SURGERY PF-TX OF FIBULA FRACTURE EACH 27781 "$1,120.00 " 960 $784.00 $560.00 $896.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98316433 PHYSICIAN FEE - SURGERY PF-TX OF FIBULA FRACTURE EACH 27784 "$1,964.00 " 960 "$1,374.80 " $982.00 "$1,571.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318090 PHYSICIAN FEE - SURGERY PF-TX OPEN METATARSAL FRACTURE EACH 28485 "$1,506.00 " 960 "$1,054.20 " $753.00 "$1,204.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98318181 PHYSICIAN FEE - SURGERY PF-TX OPEN SESAMOID BONE FRACT EACH 28531 $476.00 960 $333.20 $238.00 $380.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98335227 PHYSICIAN FEE - SURGERY PF-TX RECTAL PROLAPSE EACH 45520 $108.00 960 $75.60 $54.00 $86.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344955 PHYSICIAN FEE - SURGERY PF-UMBILICAL CORD OCCLUD W/US EACH 59072 "$1,520.00 " 960 "$1,064.00 " $760.00 "$1,216.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357452 PHYSICIAN FEE - SURGERY PF-UNLISTED PROC DENTOALVEOLAR EACH 41899 $336.00 960 $235.20 $168.00 $268.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357460 PHYSICIAN FEE - SURGERY PF-UNLISTED PROC HANDS/FINGERS EACH 26989 $302.00 960 $211.40 $151.00 $241.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357429 PHYSICIAN FEE - SURGERY PF-UNLISTED PROC NERVOUS SYST EACH 64999 $528.00 960 $369.60 $264.00 $422.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361546 PHYSICIAN FEE - SURGERY PF-UNLISTED PROCEDURE COLON EACH 45399 "$2,322.00 " 960 "$1,625.40 " "$1,161.00 " "$1,857.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361678 PHYSICIAN FEE - SURGERY PF-UNLISTED PROCEDURE LARYNX EACH 31599 "$3,359.00 " 960 "$2,351.30 " "$1,679.50 " "$2,687.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361611 PHYSICIAN FEE - SURGERY PF-UNLISTED PROCEDURE SPINE EACH 22899 $573.00 960 $401.10 $286.50 $458.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323009 PHYSICIAN FEE - SURGERY PF-UPGRADE OF PACEMAKER SYSTEM EACH 33214 "$1,312.00 " 960 $918.40 $656.00 "$1,049.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332208 PHYSICIAN FEE - SURGERY PF-UPPER GI ENDOSCOPY & INJECT EACH 43243 $628.00 960 $439.60 $314.00 $502.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358955 PHYSICIAN FEE - SURGERY PF-UPPER GI ENDOSCOPY (GERD) EACH 3130F $500.00 960 $350.00 $250.00 $400.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332166 PHYSICIAN FEE - SURGERY PF-UPPER GI ENDOSCOPY BIOPSY EACH 43239 $365.00 960 $255.50 $182.50 $292.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332182 PHYSICIAN FEE - SURGERY PF-UPPER GI ENDOSCOPY W TUBE EACH 43241 $377.00 960 $263.90 $188.50 $301.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332216 PHYSICIAN FEE - SURGERY PF-UPPER GI ENDOSCOPY/LIGATION EACH 43244 $641.00 960 $448.70 $320.50 $512.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332273 PHYSICIAN FEE - SURGERY PF-UPPER GI ENDOSCOPY/TUMOR EACH 43250 $453.00 960 $317.10 $226.50 $362.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332125 PHYSICIAN FEE - SURGERY PF-UPPR GI ENDOSCOPY DIAGNOSIS EACH 43235 $323.00 960 $226.10 $161.50 $258.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332158 PHYSICIAN FEE - SURGERY PF-UPPR GI ENDOSCPY W/US FN BX EACH 43238 $607.00 960 $424.90 $303.50 $485.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332190 PHYSICIAN FEE - SURGERY PF-UPPR GI ENDOSCPY W/US FN BX EACH 43242 $687.00 960 $480.90 $343.50 $549.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332257 PHYSICIAN FEE - SURGERY PF-UPPR GI ENDOSCPY/GUIDE WIRE EACH 43248 $437.00 960 $305.90 $218.50 $349.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332224 PHYSICIAN FEE - SURGERY PF-UPPR GI SCOPE DILATE STRICT EACH 43245 $467.00 960 $326.90 $233.50 $373.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332133 PHYSICIAN FEE - SURGERY PF-UPPR GI SCOPE W/SUBMUC INJ EACH 43236 $365.00 960 $255.50 $182.50 $292.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98332315 PHYSICIAN FEE - SURGERY PF-UPPR GI SCOPE W/THRML TXMNT EACH 43257 $623.00 960 $436.10 $311.50 $498.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339393 PHYSICIAN FEE - SURGERY PF-URETER ENDOSCOPY EACH 50970 $976.00 960 $683.20 $488.00 $780.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339369 PHYSICIAN FEE - SURGERY PF-URETER ENDOSCOPY & BIOPSY EACH 50955 $928.00 960 $649.60 $464.00 $742.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339419 PHYSICIAN FEE - SURGERY PF-URETER ENDOSCOPY & BIOPSY EACH 50974 "$1,246.00 " 960 $872.20 $623.00 $996.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339401 PHYSICIAN FEE - SURGERY PF-URETER ENDOSCOPY & CATHETER EACH 50972 $941.00 960 $658.70 $470.50 $752.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339385 PHYSICIAN FEE - SURGERY PF-URETER ENDOSCOPY & TX EACH 50961 $836.00 960 $585.20 $418.00 $668.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339427 PHYSICIAN FEE - SURGERY PF-URETER ENDOSCOPY & TX EACH 50976 "$1,230.00 " 960 $861.00 $615.00 $984.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339435 PHYSICIAN FEE - SURGERY PF-URETER ENDOSCOPY & TX EACH 50980 $937.00 960 $655.90 $468.50 $749.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341084 PHYSICIAN FEE - SURGERY PF-URETHRLYS TRANSVAG W/ SCOPE EACH 53500 "$2,015.00 " 960 "$1,410.50 " "$1,007.50 " "$1,612.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339872 PHYSICIAN FEE - SURGERY PF-URINE FLOW MEASUREMENT EACH 51736 $16.00 960 $11.20 $8.00 $12.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339203 PHYSICIAN FEE - SURGERY PF-URINE SHUNT TO INTESTINE EACH 50815 "$3,244.00 " 960 "$2,270.80 " "$1,622.00 " "$2,595.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357478 PHYSICIAN FEE - SURGERY PF-UROFLOWMETRY CPLX EACH 51741 $16.00 960 $11.20 $8.00 $12.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357643 PHYSICIAN FEE - SURGERY PF-UROLOGY SURGERY PROC NOS EACH 53899 $677.00 960 $473.90 $338.50 $541.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98304678 PHYSICIAN FEE - SURGERY PF-US BONE STIMULATION EACH 20979 $87.00 960 $60.90 $43.50 $69.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344021 PHYSICIAN FEE - SURGERY PF-VAG HYST COMPLEX EACH 58290 "$3,155.00 " 960 "$2,208.50 " "$1,577.50 " "$2,524.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344039 PHYSICIAN FEE - SURGERY PF-VAG HYST INCL T/O COMPLEX EACH 58291 "$3,408.00 " 960 "$2,385.60 " "$1,704.00 " "$2,726.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343957 PHYSICIAN FEE - SURGERY PF-VAG HYST INCLUDING T/O EACH 58262 "$2,537.00 " 960 "$1,775.90 " "$1,268.50 " "$2,029.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344047 PHYSICIAN FEE - SURGERY PF-VAG HYST T/O & REPAIR COMPL EACH 58292 "$3,593.00 " 960 "$2,515.10 " "$1,796.50 " "$2,874.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344062 PHYSICIAN FEE - SURGERY PF-VAG HYST W/ENTEROCELE COMPL EACH 58294 "$3,335.00 " 960 "$2,334.50 " "$1,667.50 " "$2,668.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343981 PHYSICIAN FEE - SURGERY PF-VAG HYST W/ENTEROCELE REP EACH 58270 "$2,445.00 " 960 "$1,711.50 " "$1,222.50 " "$1,956.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343965 PHYSICIAN FEE - SURGERY PF-VAG HYST W/T/O & VAG REPAIR EACH 58263 "$2,720.00 " 960 "$1,904.00 " "$1,360.00 " "$2,176.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343973 PHYSICIAN FEE - SURGERY PF-VAG HYST W/URINARY REPAIR EACH 58267 "$2,929.00 " 960 "$2,050.30 " "$1,464.50 " "$2,343.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343940 PHYSICIAN FEE - SURGERY PF-VAGINAL HYSTERECTOMY EACH 58260 "$2,295.00 " 960 "$1,606.50 " "$1,147.50 " "$1,836.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343056 PHYSICIAN FEE - SURGERY PF-VAGINECTOMY PARTIAL W/NODES EACH 57109 "$4,730.00 " 960 "$3,311.00 " "$2,365.00 " "$3,784.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333040 PHYSICIAN FEE - SURGERY PF-VAGOTOMY & PYLORUS REPAIR EACH 43640 "$3,384.00 " 960 "$2,368.80 " "$1,692.00 " "$2,707.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98333057 PHYSICIAN FEE - SURGERY PF-VAGOTOMY & PYLORUS REPAIR EACH 43641 "$3,423.00 " 960 "$2,396.10 " "$1,711.50 " "$2,738.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323876 PHYSICIAN FEE - SURGERY PF-VALVOTOMY PULMONARY VALVE EACH 33471 "$3,717.00 " 960 "$2,601.90 " "$1,858.50 " "$2,973.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358872 PHYSICIAN FEE - SURGERY PF-VALVULOPLASTY AORTIC VALVE EACH 33391 "$6,353.00 " 960 "$4,447.10 " "$3,176.50 " "$5,082.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359565 PHYSICIAN FEE - SURGERY PF-VALVULOPLASTY AORTIC VALVE EACH 33390 "$5,356.00 " 960 "$3,749.20 " "$2,678.00 " "$4,284.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323827 PHYSICIAN FEE - SURGERY PF-VALVULOPLASTY TRICUSPID EACH 33463 "$8,558.00 " 960 "$5,990.60 " "$4,279.00 " "$6,846.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98323835 PHYSICIAN FEE - SURGERY PF-VALVULOPLASTY TRICUSPID EACH 33464 "$6,789.00 " 960 "$4,752.30 " "$3,394.50 " "$5,431.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310568 PHYSICIAN FEE - SURGERY PF-VASC GRAFT INTO CARPAL BONE EACH 25430 "$1,693.00 " 960 "$1,185.10 " $846.50 "$1,354.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357742 PHYSICIAN FEE - SURGERY PF-VASCULAR SURG UNLISTED PROC EACH 37799 "$1,346.00 " 960 $942.20 $673.00 "$1,076.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345275 PHYSICIAN FEE - SURGERY PF-VBAC CARE AFTER DELIVERY EACH 59614 "$3,428.00 " 960 "$2,399.60 " "$1,714.00 " "$2,742.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345259 PHYSICIAN FEE - SURGERY PF-VBAC DELIVERY EACH 59610 "$7,328.00 " 960 "$5,129.60 " "$3,664.00 " "$5,862.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327877 PHYSICIAN FEE - SURGERY PF-VEIN ACCESS CUTDOWN < 1 YR EACH 36420 $135.00 960 $94.50 $67.50 $108.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327885 PHYSICIAN FEE - SURGERY PF-VEIN ACCESS CUTDOWN > 1 YR EACH 36425 $106.00 960 $74.20 $53.00 $84.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326853 PHYSICIAN FEE - SURGERY PF-VEIN BYPASS GRAFT EACH 35583 "$4,059.00 " 960 "$2,841.30 " "$2,029.50 " "$3,247.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326861 PHYSICIAN FEE - SURGERY PF-VEIN BYPASS GRAFT EACH 35585 "$4,705.00 " 960 "$3,293.50 " "$2,352.50 " "$3,764.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326879 PHYSICIAN FEE - SURGERY PF-VEIN BYPASS GRAFT EACH 35587 "$3,768.00 " 960 "$2,637.60 " "$1,884.00 " "$3,014.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357007 PHYSICIAN FEE - SURGERY PF-VISC & INFRAREN ABD 1 PROST EACH 34845 "$6,712.00 " 960 "$4,698.40 " "$3,356.00 " "$5,369.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357015 PHYSICIAN FEE - SURGERY PF-VISC & INFRAREN ABD 2 PROST EACH 34846 "$7,658.00 " 960 "$5,360.60 " "$3,829.00 " "$6,126.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357023 PHYSICIAN FEE - SURGERY PF-VISC & INFRAREN ABD 3 PROST EACH 34847 "$8,607.00 " 960 "$6,024.90 " "$4,303.50 " "$6,885.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357031 PHYSICIAN FEE - SURGERY PF-VISC & INFRAREN ABD 4+ PRST EACH 34848 "$9,555.00 " 960 "$6,688.50 " "$4,777.50 " "$7,644.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98321342 PHYSICIAN FEE - SURGERY PF-VISUALIZATION OF WINDPIPE EACH 31615 $308.00 960 $215.60 $154.00 $246.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352073 PHYSICIAN FEE - SURGERY PF-VIT FOR MACULAR HOLE EACH 67042 "$2,915.00 " 960 "$2,040.50 " "$1,457.50 " "$2,332.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352065 PHYSICIAN FEE - SURGERY PF-VIT FOR MACULAR PUCKER EACH 67041 "$2,915.00 " 960 "$2,040.50 " "$1,457.50 " "$2,332.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352081 PHYSICIAN FEE - SURGERY PF-VIT FOR MEMBRANE DISSECT EACH 67043 "$3,074.00 " 960 "$2,151.80 " "$1,537.00 " "$2,459.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336134 PHYSICIAN FEE - SURGERY PF-WEDGE BIOPSY OF LIVER EACH 47100 "$2,387.00 " 960 "$1,670.90 " "$1,193.50 " "$1,909.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322175 PHYSICIAN FEE - SURGERY PF-WEDGE RESECT LUNG INITIAL EACH 32505 "$2,604.00 " 960 "$1,822.80 " "$1,302.00 " "$2,083.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322183 PHYSICIAN FEE - SURGERY PF-WEDGE RESECT OF LUNG ADD-ON EACH 32506 $440.00 960 $308.00 $220.00 $352.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322191 PHYSICIAN FEE - SURGERY PF-WEDGE RESECT OF LUNG DIAG EACH 32507 $439.00 960 $307.30 $219.50 $351.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319064 PHYSICIAN FEE - SURGERY PF-WEDGING OF CAST EACH 29740 $190.00 960 $133.00 $95.00 $152.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319072 PHYSICIAN FEE - SURGERY PF-WEDGING OF CLUBFOOT CAST EACH 29750 $212.00 960 $148.40 $106.00 $169.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319056 PHYSICIAN FEE - SURGERY PF-WINDOWING OF CAST EACH 29730 $122.00 960 $85.40 $61.00 $97.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328420 PHYSICIAN FEE - SURGERY PF-WITHDRAWAL ARTERIAL BLOOD EACH 36600 $39.00 960 $27.30 $19.50 $31.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301823 PHYSICIAN FEE - SURGERY PF-WND PREP F/N/HF/G ADDL CM EACH 15005 $248.00 960 $173.60 $124.00 $198.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357155 PHYSICIAN FEE - SURGERY PF-WOUND CLOSURE BY ADHESIVE EACH G0168 $42.00 960 $29.40 $21.00 $33.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301807 PHYSICIAN FEE - SURGERY PF-WOUND PREP ADDL 100 CM EACH 15003 $126.00 960 $88.20 $63.00 $100.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301815 PHYSICIAN FEE - SURGERY PF-WOUND PREP F/N/HF/G EACH 15004 $691.00 960 $483.70 $345.50 $552.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98301799 PHYSICIAN FEE - SURGERY PF-WOUND PREP TRK/ARM/LEG EACH 15002 $596.00 960 $417.20 $298.00 $476.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319296 PHYSICIAN FEE - SURGERY PF-WRIST ARTHROSCOPY EACH 29840 "$1,232.00 " 960 $862.40 $616.00 $985.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319320 PHYSICIAN FEE - SURGERY PF-WRIST ARTHROSCOPY/SURGERY EACH 29845 "$1,610.00 " 960 "$1,127.00 " $805.00 "$1,288.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319304 PHYSICIAN FEE - SURGERY PF-WRIST ARTHROSCOPY/SURGERY EACH 29843 "$1,343.00 " 960 $940.10 $671.50 "$1,074.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319312 PHYSICIAN FEE - SURGERY PF-WRIST ARTHROSCOPY/SURGERY EACH 29844 "$1,368.00 " 960 $957.60 $684.00 "$1,094.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319338 PHYSICIAN FEE - SURGERY PF-WRIST ARTHROSCOPY/SURGERY EACH 29846 "$1,432.00 " 960 "$1,002.40 " $716.00 "$1,145.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319346 PHYSICIAN FEE - SURGERY PF-WRIST ARTHROSCOPY/SURGERY EACH 29847 "$1,504.00 " 960 "$1,052.80 " $752.00 "$1,203.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98319353 PHYSICIAN FEE - SURGERY PF-WRIST ENDOSCOPY/SURGERY EACH 29848 "$1,405.00 " 960 $983.50 $702.50 "$1,124.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98310642 PHYSICIAN FEE - SURGERY PF-WRIST REPLACEMENT EACH 25446 "$3,209.00 " 960 "$2,246.30 " "$1,604.50 " "$2,567.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361090 PHYSICIAN FEE - SURGERY PF-XCAPSL CTRC RMVL INSJ 1+ EACH 66991 "$1,744.00 " 960 "$1,220.80 " $872.00 "$1,395.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361082 PHYSICIAN FEE - SURGERY PF-XCPSL CTRC RMVL CPL INSJ 1+ EACH 66989 "$2,187.00 " 960 "$1,530.90 " "$1,093.50 " "$1,749.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325756 PHYSICIAN FEE - SURGERY PF-XPOSE ENDOPROSTH BRACHIAL EACH 34834 $366.00 960 $256.20 $183.00 $292.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325681 PHYSICIAN FEE - SURGERY PF-XPOSE FOR ENDOPROSTH ILIAC EACH 34820 $955.00 960 $668.50 $477.50 $764.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98325749 PHYSICIAN FEE - SURGERY PF-XPOSE FOR ENDOPROSTH ILIAC EACH 34833 "$1,115.00 " 960 $780.50 $557.50 $892.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96100417 PRO FEE - DX RADIOLOGY PF-XR NECK SOFT TISSUE EACH 70360 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501886 PRO FEES - CARDIAC CATH PF-EXPL N/FLWD SURG UXTR ART EACH 35702 "$1,140.00 " 960 $798.00 $570.00 $912.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502520 PRO FEES - CARDIAC CATH PF-L HRT CATH CHD NM/ABN NT CN EACH 93595 $643.00 960 $450.10 $321.50 $514.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502595 PRO FEES - CARDIAC CATH PF-NJX CATH SLCT P ANGRPH MAPC EACH 93575 $237.00 960 $165.90 $118.50 $189.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502579 PRO FEES - CARDIAC CATH PF-NJX CATH SLCT P-ART ANGR BI EACH 93573 $160.00 960 $112.00 $80.00 $128.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502587 PRO FEES - CARDIAC CATH PF-NJX CATH SLCT PULM VN ANGRP EACH 93574 $179.00 960 $125.30 $89.50 $143.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502561 PRO FEES - CARDIAC CATH PF-NJX CTH SLCT P-ART ANGR UNI EACH 93569 $97.00 960 $67.90 $48.50 $77.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501902 PRO FEES - CARDIAC CATH PF-PERQ TRANSCATH CLS AORTIC EACH 93591 "$2,238.00 " 975 "$1,566.60 " "$1,119.00 " "$1,790.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501894 PRO FEES - CARDIAC CATH PF-PERQ TRANSCATH CLS MITRAL EACH 93590 "$2,733.00 " 975 "$1,913.10 " "$1,366.50 " "$2,186.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97501878 PRO FEES - CARDIAC CATH PF-PRCRD DRG 6YR+ W/O CGEN CAR EACH 33017 $686.00 960 $480.20 $343.00 $548.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502512 PRO FEES - CARDIAC CATH PF-R HRT CATH CHD ABNL NT CNJ EACH 93594 $711.00 960 $497.70 $355.50 $568.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502504 PRO FEES - CARDIAC CATH PF-R HRT CATH CHD NML NT CNJ EACH 93593 $468.00 960 $327.60 $234.00 $374.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502546 PRO FEES - CARDIAC CATH PF-R&L HRT CATH CHD ABNL NT CN EACH 93597 "$1,046.00 " 960 $732.20 $523.00 $836.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97502538 PRO FEES - CARDIAC CATH PF-R&L HRT CATH CHD NML NT CNJ EACH 93596 $799.00 960 $559.30 $399.50 $639.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98563984 PRO FEES - CLINIC PF-ACUP W/STIMUL 15 MIN C EACH 97813 $0.00 960 $0.00 $0.00 $0.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98522600 PRO FEES - CLINIC PF-ACUP W/STIMUL 15 MIN RVU EACH 97813 $0.00 960 $0.00 $0.00 $0.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98564354 PRO FEES - CLINIC PF-ACUPUNCT W/STIM 15 MIN EACH 97813 $86.00 960 $60.20 $43.00 $68.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561228 PRO FEES - CLINIC PF-ANTICOAG MGT PT WARFARIN EACH 93793 $30.00 960 $21.00 $15.00 $24.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98525181 PRO FEES - CLINIC PF-BINOCULAR MICROSCOPY EACH 92504 $24.00 960 $16.80 $12.00 $19.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98557085 PRO FEES - CLINIC PF-BX LUNG/MEDIASTIN PERC EACH 32408 $396.00 960 $277.20 $198.00 $316.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98539331 PRO FEES - CLINIC PF-CHRNC CARE MGMT SVC 1ST 20 EACH 99490 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98539307 PRO FEES - CLINIC PF-CPLX CHRNC CARE 1ST 60 MIN EACH 99487 $232.00 960 $162.40 $116.00 $185.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98539315 PRO FEES - CLINIC PF-CPLX CHRNC CARE EA ADDL 30 EACH 99489 $130.00 960 $91.00 $65.00 $104.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526098 PRO FEES - CLINIC PF-DESENSITIZATION RAPID EA HR EACH 95180 $258.00 960 $180.60 $129.00 $206.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98526023 PRO FEES - CLINIC PF-G-ESOPH REFLX TST W/ELECTRD EACH 91035 $208.00 960 $145.60 $104.00 $166.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98559149 PRO FEES - CLINIC PF-NJX AA&/STRD NRV NRV JT EACH 64451 $213.00 960 $149.10 $106.50 $170.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98539299 PRO FEES - CLINIC PF-REM PHYSIOL MNTR EA ADDL 20 EACH 99458 $77.00 960 $53.90 $38.50 $61.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98564479 PRO FEES - CLINIC PF-RF ABLTJ NRV NRVTG SI JT EACH 64625 $511.00 960 $357.70 $255.50 $408.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98551195 PRO FEES - CLINIC PF-RME-DATA COLLECTION & RPT EACH 99091 $140.00 960 $98.00 $70.00 $112.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98539364 PRO FEES - CLINIC PF-SF-MEAS BP 2 READG BID 30D EACH 99474 $23.00 960 $16.10 $11.50 $18.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98539281 PRO FEES - CLINIC PF-SF-MEAS BP 2 READG BID 30D EACH 99457 $77.00 960 $53.90 $38.50 $61.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561251 PRO FEES - CLINIC PF-TELEPHONE VISIT 11-20 M EACH 99442 $169.00 960 $118.30 $84.50 $135.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561269 PRO FEES - CLINIC PF-TELEPHONE VISIT 21-30 M EACH 99443 $251.00 960 $175.70 $125.50 $200.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98561244 PRO FEES - CLINIC PF-TELEPHONE VISIT 5-10 MIN EACH 99441 $91.00 960 $63.70 $45.50 $72.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361066 PRO FEES - CLINIC PF-TRML DSTR IOS BVN 1ST 2 L/S EACH 64628 "$1,100.00 " 960 $770.00 $550.00 $880.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98361074 PRO FEES - CLINIC PF-TRML DSTRJ IOS BVN EA ADDL EACH 64629 $526.00 960 $368.20 $263.00 $420.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96501044 PRO FEES - CT PF- CT PROCEDURE NOS EACH 76497 $154.00 960 $107.80 $77.00 $123.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500316 PRO FEES - DUPLEX PF-DUP SCAN HEMO COMPL BI EACH 93985 $102.00 960 $71.40 $51.00 $81.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 99500324 PRO FEES - DUPLEX PF-DUP SCAN HEMO COMPL UNI EACH 93986 $63.00 960 $44.10 $31.50 $50.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96204532 PRO FEES - INTERVENTIONAL RADIOLOGY PF-BIOPSY LUNG OR MEDIASTINUM EACH 32408 $396.00 960 $277.20 $198.00 $316.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206370 PRO FEES - INTERVENTIONAL RADIOLOGY PF-BIOPSY LUNG/MEDIASTINUM LT EACH 32408 $396.00 960 $277.20 $198.00 $316.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96206388 PRO FEES - INTERVENTIONAL RADIOLOGY PF-BIOPSY LUNG/MEDIASTINUM RT EACH 32408 $396.00 960 $277.20 $198.00 $316.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96207709 PRO FEES - INTERVENTIONAL RADIOLOGY PF-XR NEPH/URETER/URETHRA S&I EACH 74485 $98.00 960 $68.60 $49.00 $78.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 96208061 PRO FEES - INTERVENTIONAL RADIOLOGY PF-XR VENOGRAM ADRENAL UNI S&I EACH 75840 $138.00 960 $96.60 $69.00 $110.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902985 PRO FEES - OPHTHALMOLOGY PF-INCISION OF EYE EACH 66172 "$3,053.00 " 960 "$2,137.10 " "$1,526.50 " "$2,442.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97902712 PRO FEES - OPHTHALMOLOGY PF-RPR LAC CORNEA PERF EACH 65280 "$1,714.00 " 960 "$1,199.80 " $857.00 "$1,371.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97000590 PRO FEES - PHYSICAL THERAPY PF-OT EVAL - HIGH COMPLEXITY EACH 97167 $256.00 960 $179.20 $128.00 $204.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97000566 PRO FEES - PHYSICAL THERAPY PF-OT EVAL - LOW COMPLEXITY EACH 97165 $256.00 960 $179.20 $128.00 $204.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97000574 PRO FEES - PHYSICAL THERAPY PF-OT EVAL - MODERATE COMPLEX EACH 97166 $256.00 960 $179.20 $128.00 $204.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 97000608 PRO FEES - PHYSICAL THERAPY PF-OT RE-EVALUATION EACH 97168 $178.00 960 $124.60 $89.00 $142.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902893 PRO FEES - PSYCH PF-GENETIC COUNSELING 30 MIN EACH 96040 $134.00 960 $93.80 $67.00 $107.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98902398 PRO FEES - PSYCH "PF-PSYCHOTH, 60 MIN W/E&M " EACH 90838 $276.00 960 $193.20 $138.00 $220.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345382 PRO FEES - SURGERY PF-ABORTION EACH 59851 "$1,231.00 " 960 $861.70 $615.50 $984.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98326978 PRO FEES - SURGERY PF-ARTERY BYPASS GRAFT EACH 35632 "$5,115.00 " 960 "$3,580.50 " "$2,557.50 " "$4,092.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360712 PRO FEES - SURGERY PF-ARTHROSCOPY OF JOINT NOS EACH 29999 $516.00 960 $361.20 $258.00 $412.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360563 PRO FEES - SURGERY PF-AS-AORT GRF F/AORTIC DSJ EACH 33858 "$9,485.00 " 960 "$6,639.50 " "$4,742.50 " "$7,588.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98322043 PRO FEES - SURGERY PF-BIOPSY LUNG OR MEDIASTINUM EACH 32408 $396.00 960 $277.20 $198.00 $316.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341951 PRO FEES - SURGERY PF-BIOPSY OF TESTIS EACH 54505 $556.00 960 $389.20 $278.00 $444.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348782 PRO FEES - SURGERY PF-BIOPSY/EXCISE SPINAL TUMOR EACH 63282 "$5,953.00 " 960 "$4,167.10 " "$2,976.50 " "$4,762.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98327927 PRO FEES - SURGERY PF-BL EXCH/TRANSFUSE NON-NB EACH 36455 $354.00 960 $247.80 $177.00 $283.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359821 PRO FEES - SURGERY PF-COLONOSCOPY W/STENT PLCMT EACH 44402 $684.00 960 $478.80 $342.00 $547.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360662 PRO FEES - SURGERY PF-CONJUNCTIVA UNLISTED PROC EACH 68399 $394.00 960 $275.80 $197.00 $315.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360118 PRO FEES - SURGERY PF-CONVERT NEPHROSTOMY CATH EACH 50434 $494.00 960 $345.80 $247.00 $395.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340318 PRO FEES - SURGERY PF-CYSTOSCOPY AND TREATMENT EACH 52285 $520.00 960 $364.00 $260.00 $416.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98357627 PRO FEES - SURGERY PF-DIAGNOSTIC ANOSCOPY EACH 46601 $251.00 960 $175.70 $125.50 $200.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98343817 PRO FEES - SURGERY PF-DILATION OF CERVICAL CANAL EACH 57800 $131.00 960 $91.70 $65.50 $104.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98337165 PRO FEES - SURGERY PF-DRAIN ABDOMINAL ABSCESS EACH 49020 "$4,481.00 " 960 "$3,136.70 " "$2,240.50 " "$3,584.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339526 PRO FEES - SURGERY PF-DRAIN BLADDER BY NEEDLE EACH 51100 $105.00 960 $73.50 $52.50 $84.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351331 PRO FEES - SURGERY PF-DRAINAGE OF EYE EACH 65810 "$1,187.00 " 960 $830.90 $593.50 $949.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98340748 PRO FEES - SURGERY PF-DRAINAGE OF URETHRA ABSCESS EACH 53040 "$1,044.00 " 960 $730.80 $522.00 $835.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98353774 PRO FEES - SURGERY PF-EARDRUM REVISION EACH 69450 "$1,452.00 " 960 "$1,016.40 " $726.00 "$1,161.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98331937 PRO FEES - SURGERY PF-ESOPHAGOSCPY RIGID TRNSO DX EACH 43191 $418.00 960 $292.60 $209.00 $334.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347644 PRO FEES - SURGERY PF-ESTABLISH BRAIN CAVTY SHUNT EACH 62223 "$3,050.00 " 960 "$2,135.00 " "$1,525.00 " "$2,440.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360639 PRO FEES - SURGERY PF-EXCISION GUM EA QUADRANT EACH 41820 "$3,227.00 " 975 "$2,258.90 " "$1,613.50 " "$2,581.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360670 PRO FEES - SURGERY PF-EXCISION GUM EACH QUADRANT EACH 41820 $523.00 960 $366.10 $261.50 $418.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360688 PRO FEES - SURGERY PF-EXCISION OF GUM FLAP EACH 41821 $523.00 960 $366.10 $261.50 $418.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351539 PRO FEES - SURGERY PF-INCISION OF EYE EACH 66172 "$3,053.00 " 960 "$2,137.10 " "$1,526.50 " "$2,442.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351570 PRO FEES - SURGERY PF-INSERT ANT DRAINAGE DEVICE EACH 66183 "$2,633.00 " 960 "$1,843.10 " "$1,316.50 " "$2,106.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328222 PRO FEES - SURGERY PF-INSERT PICVAD CATH EACH 36570 $935.00 960 $654.50 $467.50 $748.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360589 PRO FEES - SURGERY PF-INT HRHC TRANAL DARTLZJ 2+ EACH 46948 "$1,205.00 " 960 $843.50 $602.50 $964.00 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98338718 PRO FEES - SURGERY PF-LAPARO ABLATE RENAL MASS EACH 50542 "$3,078.00 " 960 "$2,154.60 " "$1,539.00 " "$2,462.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98359441 PRO FEES - SURGERY PF-LARYNGOPLASTY LARYNG STEN EACH 31552 "$3,968.00 " 960 "$2,777.60 " "$1,984.00 " "$3,174.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360613 PRO FEES - SURGERY PF-MNL PREP&INSJ DP RX DLVR EACH 20700 $233.00 975 $163.10 $116.50 $186.40 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350762 PRO FEES - SURGERY PF-NERVE PEDICLE TRANSFER EACH 64907 "$3,577.00 " 960 "$2,503.90 " "$1,788.50 " "$2,861.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360647 PRO FEES - SURGERY PF-PANCREAS SURG PROC NOS EACH 48999 $399.00 975 $279.30 $199.50 $319.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98345499 PRO FEES - SURGERY PF-PARTIAL THYROID EXCISION EACH 60210 "$1,958.00 " 960 "$1,370.60 " $979.00 "$1,566.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360597 PRO FEES - SURGERY PF-PRPERTL PEL PACK HEMRG TRMA EACH 49013 "$1,300.00 " 960 $910.00 $650.00 "$1,040.00 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360605 PRO FEES - SURGERY PF-REEXPLORATION PELVIC WOUND EACH 49014 "$1,077.00 " 960 $753.90 $538.50 $861.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98352164 PRO FEES - SURGERY PF-RELEASE ENCIRCLING MATERIAL EACH 67115 "$1,274.00 " 960 $891.80 $637.00 "$1,019.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346174 PRO FEES - SURGERY PF-REMOVAL OF BRAIN LESION EACH 61510 "$6,622.00 " 960 "$4,635.40 " "$3,311.00 " "$5,297.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98346406 PRO FEES - SURGERY PF-REMOVAL OF BRAIN TISSUE EACH 61543 "$6,564.00 " 960 "$4,594.80 " "$3,282.00 " "$5,251.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351844 PRO FEES - SURGERY PF-REMOVAL OF LENS MATERIAL EACH 66850 "$2,013.00 " 960 "$1,409.10 " "$1,006.50 " "$1,610.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98348899 PRO FEES - SURGERY PF-REMOVAL OF VERTEBRAL BODY EACH 63304 "$7,093.00 " 960 "$4,965.10 " "$3,546.50 " "$5,674.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98350291 PRO FEES - SURGERY PF-REMOVE SCIATIC NERVE LESION EACH 64786 "$2,853.00 " 960 "$1,997.10 " "$1,426.50 " "$2,282.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341837 PRO FEES - SURGERY PF-REP MULTI-COMP PENIS PROS EACH 54408 "$2,102.00 " 960 "$1,471.40 " "$1,051.00 " "$1,681.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98358542 PRO FEES - SURGERY PF-REPAIR CORPOREAL TEAR EACH 34704 "$6,428.00 " 960 "$4,499.60 " "$3,214.00 " "$5,142.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98351059 PRO FEES - SURGERY PF-REPAIR OF EYE WOUND EACH 65280 "$1,714.00 " 960 "$1,199.80 " $857.00 "$1,371.20 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98342249 PRO FEES - SURGERY PF-REPAIR OF HYDROCELE EACH 55060 "$1,012.00 " 960 $708.40 $506.00 $809.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98347487 PRO FEES - SURGERY PF-REPAIR OF SKULL WITH GRAFT EACH 62146 "$3,766.00 " 960 "$2,636.20 " "$1,883.00 " "$3,012.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98341761 PRO FEES - SURGERY PF-REPAIR PENIS EACH 54380 "$2,122.00 " 960 "$1,485.40 " "$1,061.00 " "$1,697.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98328297 PRO FEES - SURGERY PF-REPLACE TUNNELED CV CATH EACH 36582 $774.00 960 $541.80 $387.00 $619.20 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98344799 PRO FEES - SURGERY PF-RESECT RECURRENT GYN MAL EACH 58957 "$4,353.00 " 960 "$3,047.10 " "$2,176.50 " "$3,482.40 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98336902 PRO FEES - SURGERY PF-RESECT/DEBRIDE PANCREAS EACH 48105 "$7,857.00 " 960 "$5,499.90 " "$3,928.50 " "$6,285.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98349657 PRO FEES - SURGERY PF-REVISE/REPL VAGUS N ELTRD EACH 64569 "$2,262.00 " 960 "$1,583.40 " "$1,131.00 " "$1,809.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360696 PRO FEES - SURGERY PF-RMVL DEEP RX DELIVERY DEV EACH 20701 $177.00 960 $123.90 $88.50 $141.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98360571 PRO FEES - SURGERY PF-TRANSVRS A-ARCH GRF HYPTHRM EACH 33871 "$9,102.00 " 960 "$6,371.40 " "$4,551.00 " "$7,281.60 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 98339377 PRO FEES - SURGERY PF-URETER ENDOSCOPY & TX EACH 50957 $932.00 960 $652.40 $466.00 $745.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 46000006 PULMONARY AEROSOL INHALATION PENTAMIDINE EACH 94642 $528.00 410 $369.60 $264.00 $422.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000014 PULMONARY AEROSOL NEB/MDI/IPPB DEMO/EVAL EACH 94664 $528.00 410 $369.60 $264.00 $422.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000485 PULMONARY ARTERIAL PUNCTURE FOR SPEC EACH 36600 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 46000055 PULMONARY BREATHING RESPONSE HYPOXIA EACH 94450 $387.00 460 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000550 PULMONARY BRONCHOPROVOCATION EVALUATION EACH 95070 "$1,326.00 " 924 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 46000527 PULMONARY C02/MEMBANE DIFFUSE CAPACITY EACH 94729 $156.00 460 $109.20 $78.00 $124.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000543 PULMONARY CAR SEAT/BED TEST + 30 MIN EACH 94781 $114.00 460 $79.80 $57.00 $91.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000535 PULMONARY CAR SEAT/BED TEST 60 MIN EACH 94780 $100.00 460 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000071 PULMONARY CHEST PHYSIOTHRPY INITIAL EACH 94667 $316.00 410 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000089 PULMONARY CHEST PHYSIOTHRPY SUBSEQ EACH 94668 $316.00 410 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000097 PULMONARY CNP INITIATION/MANAGEMENT EACH 94662 "$1,550.00 " 410 "$1,085.00 " $775.00 "$1,240.00 " 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000113 PULMONARY CONTINUOUS INHAL TX 1ST HR EACH 94644 $316.00 410 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000121 PULMONARY CONTINUOUS INHAL TX EA ADDL HR EACH 94645 $117.00 410 $81.90 $58.50 $93.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000139 PULMONARY CPAP/BIPAP INITIATION/MANAGE EACH 94660 $528.00 410 $369.60 $264.00 $422.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000147 PULMONARY CPR EACH 92950 $777.00 410 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000451 PULMONARY EKG 12 LEAD TRACING EACH 93005 $152.00 730 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $77/visit $70/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000162 PULMONARY FLOW VOLUME LOOP EACH 94375 $777.00 460 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000170 PULMONARY MAXIMUM VOLUNTARY VENT EACH 94200 $152.00 460 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000212 PULMONARY NONPRESSURIZED INHALATION EACH 94640 $528.00 410 $369.60 $264.00 $422.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000220 PULMONARY O2 UPTAKE EXPIRED GAS REST EACH 94690 $152.00 460 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000238 PULMONARY O2 UPTAKE EXPIRED GAS REST/EXR EACH 94680 $387.00 460 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000246 PULMONARY O2 UPTAKE EXPIRED GAS W/CO2 EACH 94681 $777.00 460 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000659 PULMONARY PHY/QHP OP PULM RHB W/MNTR EACH 94626 $152.00 460 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000642 PULMONARY PHY/QHP OP PULM RHB W/O MNTR EACH 94625 $152.00 460 $106.40 $76.00 $121.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000253 PULMONARY PNEUMOGRAM PEDS 12-24 HR EACH 94772 "$1,326.00 " 460 $928.20 $663.00 "$1,060.80 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000519 PULMONARY PULM FUNCT TEST OSCILLOMETRY EACH 94728 $387.00 460 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000493 PULMONARY PULM FUNCT TST PLETHYSMOGRAP EACH 94726 $777.00 460 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000501 PULMONARY PULM FUNCTION TEST BY GAS EACH 94727 $387.00 460 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000279 PULMONARY PULMONARY STRESS TEST CPLX EACH 94621 $777.00 460 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000287 PULMONARY PULMONARY STRESS TEST SMP EACH 94618 $316.00 460 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000295 PULMONARY PULSE OX MULTIPLE EACH 94761 $77.00 460 $53.90 $38.50 $61.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000303 PULMONARY PULSE OX OVERNIGHT EACH 94762 $387.00 460 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000311 PULMONARY PULSE OX SINGLE EACH 94760 $39.00 460 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000337 PULMONARY RESP FUNCTION 15 MIN EACH G0238 $74.00 410 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000345 PULMONARY RESP FUNCTION GROUP EACH G0239 $100.00 410 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000352 PULMONARY RESP STRENGTH/ENDURANCE 15 MIN EACH G0237 $74.00 410 $51.80 $37.00 $59.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000360 PULMONARY SPIROMETRY/PFT EACH 94010 $387.00 460 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000378 PULMONARY SPIROMETRY/PFT CPLX EACH 94070 $777.00 460 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000394 PULMONARY SPIROMETRY/PFT PRE & POST EACH 94060 $777.00 460 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000402 PULMONARY SURFACTANT ADMIN BY DR THRU TB EACH 94610 $528.00 469 $369.60 $264.00 $422.40 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000469 PULMONARY UNLISTED PULMONARY SERVICE EACH 94799 $387.00 460 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000428 PULMONARY VENT MANGMNT INPT/OBS INIT DAY EACH 94002 "$1,550.00 " 410 "$1,085.00 " $775.00 "$1,240.00 " 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000436 PULMONARY VENT MANGMNT INPT/OBS SUBS DAY EACH 94003 "$1,550.00 " 410 "$1,085.00 " $775.00 "$1,240.00 " 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 46000444 PULMONARY VITAL CAPACITY TOTAL EACH 94150 $387.00 460 $270.90 $193.50 $309.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301094 RADIATION THERAPY APPLY SURFACE RADIATION EACH 77789 $297.00 342 $207.90 $148.50 $237.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $120.60 Non Payable Non Payable 33300005 RADIATION THERAPY BRACHY LS NS PALADIUM-103 /1MM EACH C2636 $141.00 278 $98.70 $70.50 $112.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300013 RADIATION THERAPY BRACHY NON-STRANDED I-125 PER EACH C2639 $91.00 278 $63.70 $45.50 $72.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300021 RADIATION THERAPY BRACHY NON-STRN CESIUM 131 PER EACH C2643 $209.00 278 $146.30 $104.50 $167.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300039 RADIATION THERAPY BRACHY NON-STRND NOS PER SRCE EACH C2699 $91.00 278 $63.70 $45.50 $72.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300047 RADIATION THERAPY BRACHY NON-STRND PALLADM-103 EACH C2641 $192.00 278 $134.40 $96.00 $153.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300054 RADIATION THERAPY BRACHY N-S HA I-125 > 1.01MCI EACH C2634 $392.00 278 $274.40 $196.00 $313.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300062 RADIATION THERAPY BRACHY NS HA PALADIUM-103 >2.2 EACH C2635 $154.00 278 $107.80 $77.00 $123.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300088 RADIATION THERAPY BRACHY STRANDED CESIUM 131 PER EACH C2642 $254.00 278 $177.80 $127.00 $203.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300096 RADIATION THERAPY BRACHY STRANDED I-125 PER EACH C2638 $109.00 278 $76.30 $54.50 $87.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300104 RADIATION THERAPY BRACHY STRND NOS PER SOURCE EACH C2698 $109.00 278 $76.30 $54.50 $87.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33300112 RADIATION THERAPY BRACHY STRND PALLADM-103 EACH C2640 $198.00 278 $138.60 $99.00 $158.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 33301169 RADIATION THERAPY BRACHYTX ISODOSE COMPLEX EACH 77318 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301151 RADIATION THERAPY BRACHYTX ISODOSE INTERMEDIATE EACH 77317 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301144 RADIATION THERAPY BRACHYTX ISODOSE PLAN SIMPLE EACH 77316 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301102 RADIATION THERAPY CT GUIDE PLACE RAD THER FIELDS EACH 77014 $587.00 333 $410.90 $293.50 $469.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300146 RADIATION THERAPY DOSIMETRY CALCULATION BASIC EACH 77300 $336.00 333 $235.20 $168.00 $268.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300153 RADIATION THERAPY DOSIMETRY CALCULATION SPECIAL EACH 77331 $336.00 333 $235.20 $168.00 $268.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301003 RADIATION THERAPY EXTERNAL RADIATION DOSIMETRY EACH 77399 $336.00 333 $235.20 $168.00 $268.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301193 RADIATION THERAPY GUIDANCE FOR RADIATION TX DLVR EACH 77387 $0.00 333 $0.00 $0.00 $0.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301060 RADIATION THERAPY I/O RADIATION TX MANAGEMENT EACH 77469 $443.00 333 $310.10 $221.50 $354.40 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301185 RADIATION THERAPY IMRT - COMPLEX EACH 77386 "$1,456.00 " 333 "$1,019.20 " $728.00 "$1,164.80 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301086 RADIATION THERAPY INFUSE RADIOACTIVE MATERIALS EACH 77750 $665.00 342 $465.50 $332.50 $532.00 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $361.18 Non Payable Non Payable 33300286 RADIATION THERAPY INTENSITY MOD TX PLAN EACH 77301 "$3,426.00 " 333 "$2,398.20 " "$1,713.00 " "$2,740.80 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300294 RADIATION THERAPY INTERSTITIAL BRACHY CPLX EACH 77778 "$1,773.00 " 342 "$1,241.10 " $886.50 "$1,418.40 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $814.33 Non Payable Non Payable 33300328 RADIATION THERAPY INTRACAVITARY BRACHY CPLX EACH 77763 "$1,773.00 " 342 "$1,241.10 " $886.50 "$1,418.40 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $709.63 Non Payable Non Payable 33300336 RADIATION THERAPY INTRACAVITARY BRACHY INTERMED EACH 77762 "$1,456.00 " 342 "$1,019.20 " $728.00 "$1,164.80 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $502.94 Non Payable Non Payable 33300344 RADIATION THERAPY INTRACAVITARY BRACHY SMP EACH 77761 "$1,456.00 " 342 "$1,019.20 " $728.00 "$1,164.80 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $379.01 Non Payable Non Payable 33300427 RADIATION THERAPY MEDICAL PHYSICS CONTINUING EACH 77336 $336.00 333 $235.20 $168.00 $268.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300948 RADIATION THERAPY MLC DEVICE CONSTRUCT/IMRT PLAN EACH 77338 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301037 RADIATION THERAPY NEUTRON BEAM TX COMPLEX EACH 77423 "$1,456.00 " 333 "$1,019.20 " $728.00 "$1,164.80 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300468 RADIATION THERAPY PORT PLAN SPECIAL EACH 77321 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300559 RADIATION THERAPY RAD THPY BREAST APPL PLACE/REM EACH C9726 "$3,903.00 " 333 "$2,732.10 " "$1,951.50 " "$3,122.40 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300658 RADIATION THERAPY RAD THRPY PORT FILM(S) EACH 77417 $112.00 333 $78.40 $56.00 $89.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300955 RADIATION THERAPY RADIATION PHYSICS CONSULT EACH 77370 $336.00 333 $235.20 $168.00 $268.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300575 RADIATION THERAPY RADIATION THERAPY COMPLEX EACH 77412 $665.00 333 $465.50 $332.50 $532.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300625 RADIATION THERAPY RADIATION THERAPY INTERMEDIATE EACH 77407 $665.00 333 $465.50 $332.50 $532.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300674 RADIATION THERAPY RADIATION THERAPY SIMPLE EACH 77402 $297.00 333 $207.90 $148.50 $237.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301011 RADIATION THERAPY RADIATION TREATMENT DELIVERY EACH 77401 $297.00 333 $207.90 $148.50 $237.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301219 RADIATION THERAPY RADIATION TX DELIVERY IMRT EACH 77385 "$1,456.00 " 333 "$1,019.20 " $728.00 "$1,164.80 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300724 RADIATION THERAPY RADIOELEMENT HANDLING/LOADING EACH 77790 $266.00 342 $186.20 $133.00 $212.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $14.46 Non Payable Non Payable 33300989 RADIATION THERAPY "ROBOT LIN-RADSURG COM, FIRST " EACH G0339 "$8,425.00 " 333 "$5,897.50 " "$4,212.50 " "$6,740.00 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300997 RADIATION THERAPY ROBT LIN-RADSURG FRACTX 2-5 EACH G0340 "$6,295.00 " 333 "$4,406.50 " "$3,147.50 " "$5,036.00 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300740 RADIATION THERAPY SIMULATION 3-D/CT GUIDED EACH 77295 "$3,426.00 " 333 "$2,398.20 " "$1,713.00 " "$2,740.80 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300757 RADIATION THERAPY SIMULATION CPLX EACH 77290 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300765 RADIATION THERAPY SIMULATION INTERMED EACH 77285 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300773 RADIATION THERAPY SIMULATION SMP EACH 77280 $336.00 333 $235.20 $168.00 $268.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301078 RADIATION THERAPY SPECIAL RADIATION TREATMENT EACH 77470 "$1,456.00 " 333 "$1,019.20 " $728.00 "$1,164.80 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300815 RADIATION THERAPY STEREOTACTIC MGT TRT 1 SESSION EACH 77432 "$2,970.00 " 333 "$2,079.00 " "$1,485.00 " "$2,376.00 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300971 RADIATION THERAPY STEREOTACTIC RADIATION TRMT EACH 77435 $212.00 333 $148.40 $106.00 $169.60 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301136 RADIATION THERAPY TELETHX ISODOSE PLAN COMPLEX EACH 77307 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33301128 RADIATION THERAPY TELETHX ISODOSE PLAN SIMPLE EACH 77306 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300856 RADIATION THERAPY TREATMENT DEVICE CPLX EACH 77334 $914.00 333 $639.80 $457.00 $731.20 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300864 RADIATION THERAPY TREATMENT DEVICE INTERMED EACH 77333 $336.00 333 $235.20 $168.00 $268.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300872 RADIATION THERAPY TREATMENT DEVICE SMP EACH 77332 $336.00 333 $235.20 $168.00 $268.80 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300914 RADIATION THERAPY WEEKLY MGMT 5 TREATMENTS EACH 77427 $325.00 333 $227.50 $162.50 $260.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 33300922 RADIATION THERAPY WEEKLY MGT 1-2 FRACTIONS ONLY EACH 77431 $216.60 333 $151.62 $108.30 $173.28 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 35900836 RADIOLOGY - CT CORONARY ARTERY W/CALC.SCORING EACH 75571 $225.00 350 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $36.09 $36.09 $111.23 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900000 RADIOLOGY - CT CT 3D REND W/INTERP W/O PSTPR EACH 76376 $329.00 350 $230.30 $164.50 $263.20 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $24.78 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900810 RADIOLOGY - CT CT ABD & PELVIS W/ CONTRAST EACH 74177 $951.00 352 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $239.85 $239.85 $346.79 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900802 RADIOLOGY - CT CT ABD & PELVIS W/O CONTRAST EACH 74176 $606.00 352 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $155.08 $155.08 $212.32 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900828 RADIOLOGY - CT CT ABD&PELVIS 1+ SECTION/REGNS EACH 74178 $951.00 352 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $267.39 $267.39 $389.33 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900026 RADIOLOGY - CT CT ABDOMEN W&W/O CONTRAST EACH 74170 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $265.56 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900034 RADIOLOGY - CT CT ABDOMEN W/CONTRAST EACH 74160 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $258.03 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900042 RADIOLOGY - CT CT ABDOMEN W/O CONTRAST EACH 74150 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $158.37 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900901 RADIOLOGY - CT CT ANGIO ABD&PELV W/O&W/DYE EACH 74174 $951.00 359 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $464.83 $464.83 $429.43 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900794 RADIOLOGY - CT CT ANGIO HRT W/3D IMAGE EACH 75574 $455.00 350 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $215.32 $215.32 $315.79 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900067 RADIOLOGY - CT CT BONE MINERAL DENSITY AXIAL EACH 77078 $225.00 352 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $58.00 $58.00 $96.34 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900869 RADIOLOGY - CT CT BRAIN PERFUSION SCAN EACH 0042T "$1,725.00 " 351 "$1,207.50 " $862.50 "$1,380.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $391.61 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900083 RADIOLOGY - CT CT CERVICAL SPINE W&WO CONT EACH 72127 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $243.78 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900091 RADIOLOGY - CT CT CERVICAL SPINE W/CONTRAST EACH 72126 $951.00 352 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $207.08 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900109 RADIOLOGY - CT CT CERVICAL SPINE W/O CONTRAS EACH 72125 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $165.01 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900125 RADIOLOGY - CT CT FOLLOW UP/LIMITED STUDY EACH 76380 $225.00 350 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $87.85 $87.85 $135.04 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900133 RADIOLOGY - CT CT FOS/SEL/EAR W&W/O CONTRAST EACH 70482 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $257.59 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900141 RADIOLOGY - CT CT FOS/SEL/EAR W/CONTRAST EACH 70481 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $236.49 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900158 RADIOLOGY - CT CT FOS/SEL/EAR W/O CONTRAST EACH 70480 $272.00 351 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $185.27 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900174 RADIOLOGY - CT CT GUIDED LOCALIZATION STEREO EACH 77011 "$1,080.99 " 350 $756.69 $540.50 $864.79 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $248.15 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900224 RADIOLOGY - CT CT HEAD/BRAIN W&W/O CONTRAST EACH 70470 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $202.53 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900232 RADIOLOGY - CT CT HEAD/BRAIN W/CONTRAST EACH 70460 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $172.75 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900240 RADIOLOGY - CT CT HEAD/BRAIN W/O CONTRAST EACH 70450 $272.00 351 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $122.81 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900893 RADIOLOGY - CT CT HRT W/3D IMAGE EACH 75572 $455.00 359 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $215.32 $215.32 $264.06 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900885 RADIOLOGY - CT CT HRT W/3D IMAGE CONGEN EACH 75573 $455.00 359 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $215.32 $215.32 $325.55 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900331 RADIOLOGY - CT CT LUMBAR SP W&WO CONTRAST EACH 72133 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $242.65 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900349 RADIOLOGY - CT CT LUMBAR SPINE W/CONTRAST EACH 72132 $951.00 352 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $207.46 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900356 RADIOLOGY - CT CT LUMBAR SPINE W/O CONTRAST EACH 72131 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $164.26 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900364 RADIOLOGY - CT CT LWR EXT W&W/O CONTRAST BI EACH 73702 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $246.83 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900372 RADIOLOGY - CT CT LWR EXT W&W/O CONTRAST LT EACH 73702 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $246.83 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900307 RADIOLOGY - CT CT LWR EXT W&W/O CONTRAST RT EACH 73702 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $246.83 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900380 RADIOLOGY - CT CT LWR EXT W/CONTRAST BILAT EACH 73701 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $204.96 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900398 RADIOLOGY - CT CT LWR EXT W/CONTRAST LT EACH 73701 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $204.96 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900323 RADIOLOGY - CT CT LWR EXT W/CONTRAST RT EACH 73701 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $204.96 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900406 RADIOLOGY - CT CT LWR EXT W/O CONTRAST BILAT EACH 73700 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $164.26 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900414 RADIOLOGY - CT CT LWR EXT W/O CONTRAST LT EACH 73700 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $164.26 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900315 RADIOLOGY - CT CT LWR EXT W/O CONTRAST RT EACH 73700 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $164.26 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900422 RADIOLOGY - CT CT MAX/FACIAL W&W/O CONTRAST EACH 70488 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $215.65 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900430 RADIOLOGY - CT CT MAX/FACIAL W/CONTRAST EACH 70487 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $176.87 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900448 RADIOLOGY - CT CT MAX/FACIAL W/O CONTRAST EACH 70486 $272.00 351 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $147.93 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900455 RADIOLOGY - CT CT NECK W&W/O CONTRAST EACH 70492 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $259.70 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900463 RADIOLOGY - CT CT NECK W/CONTRAST EACH 70491 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $214.41 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900471 RADIOLOGY - CT CT NECK W/O CONTRAST EACH 70490 $272.00 351 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $174.40 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900489 RADIOLOGY - CT CT PELVIS W&W/O CONTRAST EACH 72194 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $255.39 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900497 RADIOLOGY - CT CT PELVIS W/CONTRAST EACH 72193 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $251.46 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900505 RADIOLOGY - CT CT PELVIS W/O CONTRAST EACH 72192 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $154.04 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900877 RADIOLOGY - CT CT PROCEDURE NOS EACH 76497 $225.00 351 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $87.85 $87.85 $114.20 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900513 RADIOLOGY - CT CT THORACIC SP W&WO CONTRAST EACH 72130 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $244.15 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900521 RADIOLOGY - CT CT THORACIC SPINE W/CONTRAST EACH 72129 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $208.58 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900539 RADIOLOGY - CT CT THORACIC SPINE WO CONTRAST EACH 72128 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $165.01 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900547 RADIOLOGY - CT CT THORAX W&W/O CONTRAST EACH 71270 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $245.53 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900117 RADIOLOGY - CT CT THORAX W/CONTRAST EACH 71260 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $207.81 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900554 RADIOLOGY - CT CT THORAX W/O CONTRAST EACH 71250 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $167.47 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900562 RADIOLOGY - CT CT UPPER EXTREMITY W&WO CON RT EACH 73202 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $255.39 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900596 RADIOLOGY - CT CT UPR EXT W&W/O CONT BILAT EACH 73202 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $255.39 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900604 RADIOLOGY - CT CT UPR EXT W&W/O CONTRAST LT EACH 73202 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $266.82 $266.82 $255.39 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900612 RADIOLOGY - CT CT UPR EXT W/CONTRAST BILAT EACH 73201 $951.00 352 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $235.34 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900620 RADIOLOGY - CT CT UPR EXT W/CONTRAST LT EACH 73201 $951.00 352 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $235.34 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900570 RADIOLOGY - CT CT UPR EXT W/CONTRAST RT EACH 73201 $951.00 352 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $235.34 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900638 RADIOLOGY - CT CT UPR EXT W/O CONTRAST BILAT EACH 73200 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $170.64 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900646 RADIOLOGY - CT CT UPR EXT W/O CONTRAST LT EACH 73200 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $170.64 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900588 RADIOLOGY - CT CT UPR EXT W/O CONTRAST RT EACH 73200 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $156.06 $156.06 $170.64 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900679 RADIOLOGY - CT CTA ABDOMEN W/CONTRAST EACH 74175 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $287.17 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900687 RADIOLOGY - CT CTA CHEST W & IF DONE W/O CON EACH 71275 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $287.54 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900703 RADIOLOGY - CT CTA HEAD& IF DONE POST PROCESS EACH 70496 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $283.87 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900711 RADIOLOGY - CT CTA LWR EXT W/&WO CONTRAST RT EACH 73706 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $290.46 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900729 RADIOLOGY - CT CTA LWR EXT W/CONTRAST BILAT EACH 73706 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $290.46 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900737 RADIOLOGY - CT CTA LWR EXT W/CONTRAST LT EACH 73706 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $290.46 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900745 RADIOLOGY - CT CTA NECK W& IF DONE WO & POST EACH 70498 $455.00 351 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $283.87 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900752 RADIOLOGY - CT CTA PELVIS W& IF DONE WO CON EACH 72191 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $286.05 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900760 RADIOLOGY - CT CTA UPR EXT W& IF WO CONT LT EACH 73206 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $286.05 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900786 RADIOLOGY - CT CTA UPR EXT W& IF WO CONT RT EACH 73206 $455.00 352 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $272.38 $272.38 $286.05 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 35900059 RADIOLOGY - CT DXA BONE DENSITY/PERIPHERAL EACH 77081 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $23.29 Non Payable $30.73 65% of Billed Charges 65% of Billed Charges 35900844 RADIOLOGY - CT LDCT LUNG CANCER SCREENING EACH G0297 $272.00 352 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable Non Payable $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 32001869 RADIOLOGY - DX ADD XR MANDIBLE <4V LT EACH 70100 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $34.75 65% of Billed Charges 65% of Billed Charges 32307613 RADIOLOGY - DX BX RENAL NEEDLE PERC RT EACH 50200 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305575 RADIOLOGY - DX DX BRONCHOSCOPE/BRUSHING EACH 31623 "$4,197.00 " 510 "$2,937.90 " "$2,098.50 " "$3,357.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307027 RADIOLOGY - DX ESOPHAGOSCOP STENT PLACEMENT EACH 43212 "$14,092.00 " 510 "$9,864.40 " "$7,046.00 " "$11,273.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32000630 RADIOLOGY - DX FLUOROGUIDE FOR SPINE INJECT EACH 77003 $200.00 320 $140.00 $100.00 $160.00 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $95.64 65% of Billed Charges 65% of Billed Charges 32002677 RADIOLOGY - DX INS ENDOVAS VENA CAVA FILTR EACH 37191 "$13,588.00 " 320 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $243.92 65% of Billed Charges 65% of Billed Charges 32307050 RADIOLOGY - DX PLACE GASTROSTOMY TUBE EACH 43246 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309569 RADIOLOGY - DX RENAL BIOPSY PERCUTANEOUS LT EACH 50200 "$4,009.00 " 320 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $132.97 65% of Billed Charges 65% of Billed Charges 32002453 RADIOLOGY - DX XR AC JOINT W/O WTS UNI EACH 73050 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.75 65% of Billed Charges 65% of Billed Charges 32000044 RADIOLOGY - DX XR AC JOINTS BILAT W/O WTS EACH 73050 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.75 65% of Billed Charges 65% of Billed Charges 32002313 RADIOLOGY - DX XR ANKLE 1V LT EACH 73600 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $30.10 65% of Billed Charges 65% of Billed Charges 32002297 RADIOLOGY - DX XR ANKLE 1V RT EACH 73600 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $30.10 65% of Billed Charges 65% of Billed Charges 32000069 RADIOLOGY - DX XR ANKLE 2V BILAT EACH 73600 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $30.10 65% of Billed Charges 65% of Billed Charges 32000077 RADIOLOGY - DX XR ANKLE 2V LT EACH 73600 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $30.10 65% of Billed Charges 65% of Billed Charges 32000051 RADIOLOGY - DX XR ANKLE 2V RT EACH 73600 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $30.10 65% of Billed Charges 65% of Billed Charges 32002172 RADIOLOGY - DX XR ANKLE 3+V BIL EACH 73610 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $33.09 65% of Billed Charges 65% of Billed Charges 32002180 RADIOLOGY - DX XR ANKLE 3+V LT EACH 73610 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $33.09 65% of Billed Charges 65% of Billed Charges 32000085 RADIOLOGY - DX XR ANKLE 3+V RT EACH 73610 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $33.09 65% of Billed Charges 65% of Billed Charges 32302622 RADIOLOGY - DX XR ARTHROGRAM TMJ EACH 70332 $606.00 322 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $77.01 65% of Billed Charges 65% of Billed Charges 32304222 RADIOLOGY - DX XR ARTHROGRAM WRIST BIL S&I EACH 73115 $951.00 322 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $119.39 65% of Billed Charges 65% of Billed Charges 32308660 RADIOLOGY - DX XR ARTHROGRAM WRIST S&I LT EACH 73115 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $119.39 65% of Billed Charges 65% of Billed Charges 32308678 RADIOLOGY - DX XR ARTHROGRAM WRIST S&I RT EACH 73115 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $119.39 65% of Billed Charges 65% of Billed Charges 32000119 RADIOLOGY - DX XR BONE AGE STUDIES EACH 77072 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $24.06 65% of Billed Charges 65% of Billed Charges 32000127 RADIOLOGY - DX XR BONE DENSITY (SEXA) APPEND EACH G0130 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $35.63 65% of Billed Charges 65% of Billed Charges 32000168 RADIOLOGY - DX XR BONE LENGTH STUDIES EACH 77073 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $41.96 65% of Billed Charges 65% of Billed Charges 32000176 RADIOLOGY - DX XR BONE SURVEY COMPLETE EACH 77075 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 $60.18 $90.01 65% of Billed Charges 65% of Billed Charges 32000184 RADIOLOGY - DX XR BONE SURVEY INFANT EACH 77076 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 $60.18 $97.21 65% of Billed Charges 65% of Billed Charges 32000192 RADIOLOGY - DX XR BONE SURVEY LIMITED EACH 77074 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 $60.18 $59.81 65% of Billed Charges 65% of Billed Charges 32002339 RADIOLOGY - DX XR CALCANEUS 2+V BIL EACH 73650 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $26.76 65% of Billed Charges 65% of Billed Charges 32002321 RADIOLOGY - DX XR CALCANEUS 2+V LT EACH 73650 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $26.76 65% of Billed Charges 65% of Billed Charges 32000200 RADIOLOGY - DX XR CALCANEUS 2+V RT EACH 73650 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $26.76 65% of Billed Charges 65% of Billed Charges 32000234 RADIOLOGY - DX XR CERVICAL SPINE COMP W/OBL/F EACH 72052 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 Non Payable $55.99 65% of Billed Charges 65% of Billed Charges 32303836 RADIOLOGY - DX XR CHANGE TUBE DRAIN CATH S&I EACH 75984 $769.00 320 $538.30 $384.50 $615.20 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $94.07 65% of Billed Charges 65% of Billed Charges 32000267 RADIOLOGY - DX XR CHEST 2 VIEWS W/FLUORO EACH 71046 $225.00 324 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $49.69 $49.69 $31.04 65% of Billed Charges 65% of Billed Charges 32000325 RADIOLOGY - DX XR CHOLANGIOGRAM OR EACH 74300 $384.75 320 $269.33 $192.38 $307.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $50.31 65% of Billed Charges 65% of Billed Charges 32000382 RADIOLOGY - DX XR CLAVICLE CMPL BIL EACH 73000 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.77 65% of Billed Charges 65% of Billed Charges 32000390 RADIOLOGY - DX XR CLAVICLE CMPL LT EACH 73000 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.77 65% of Billed Charges 65% of Billed Charges 32000408 RADIOLOGY - DX XR CLAVICLE CMPL RT EACH 73000 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.77 65% of Billed Charges 65% of Billed Charges 32000416 RADIOLOGY - DX XR COLON ENEMA BARIUM EACH 74270 $455.00 320 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $70.02 $70.02 $145.49 65% of Billed Charges 65% of Billed Charges 32000440 RADIOLOGY - DX XR C-SPINE 2-3V EACH 72040 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $36.05 65% of Billed Charges 65% of Billed Charges 32302986 RADIOLOGY - DX XR CYSTOURETHROGRAM RETROGRADE EACH 74450 $606.00 320 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $137.30 $137.30 $220.48 65% of Billed Charges 65% of Billed Charges 32302994 RADIOLOGY - DX XR CYSTOURETHROGRAM VOID S&I EACH 74455 $606.00 320 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $137.30 $137.30 $91.67 65% of Billed Charges 65% of Billed Charges 32303034 RADIOLOGY - DX XR DIL NEPH/URETER/URETHRA S& EACH 74485 "$5,037.00 " 320 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% of Billed Charges 80% of Billed Charges $918.58 $918.58 $106.76 65% of Billed Charges 65% of Billed Charges 32000465 RADIOLOGY - DX XR ELBOW 2V BIL EACH 73070 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $27.10 65% of Billed Charges 65% of Billed Charges 32000473 RADIOLOGY - DX XR ELBOW 2V LT EACH 73070 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $27.10 65% of Billed Charges 65% of Billed Charges 32000481 RADIOLOGY - DX XR ELBOW 2V RT EACH 73070 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $27.10 65% of Billed Charges 65% of Billed Charges 32001984 RADIOLOGY - DX XR ELBOW CMPL 3+V BIL EACH 73080 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.42 65% of Billed Charges 65% of Billed Charges 32002248 RADIOLOGY - DX XR ELBOW CMPL 3+V LT EACH 73080 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.42 65% of Billed Charges 65% of Billed Charges 32000499 RADIOLOGY - DX XR ELBOW CMPL 3+V RT EACH 73080 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.42 65% of Billed Charges 65% of Billed Charges 32303729 RADIOLOGY - DX XR ENDOV RPR THORACIC DIST S&I EACH 75959 $934.19 320 $653.93 $467.10 $747.35 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $176.92 65% of Billed Charges 65% of Billed Charges 32303711 RADIOLOGY - DX XR ENDOV RPR THORACIC PROX S&I EACH 75958 "$1,106.31 " 320 $774.42 $553.16 $885.05 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $200.46 65% of Billed Charges 65% of Billed Charges 32303703 RADIOLOGY - DX XR ENDOV RPR THORACIC WO L S&I EACH 75957 "$1,430.59 " 320 "$1,001.41 " $715.30 "$1,144.47 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $304.29 65% of Billed Charges 65% of Billed Charges 32303695 RADIOLOGY - DX XR ENDOVAS RPR THORAC W/LT S&I EACH 75956 "$1,288.30 " 320 $901.81 $644.15 "$1,030.64 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $354.79 65% of Billed Charges 65% of Billed Charges 32000515 RADIOLOGY - DX XR ENEMA BARIUM W/AIR EACH 74280 $455.00 320 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $113.25 $113.25 $208.96 65% of Billed Charges 65% of Billed Charges 32302887 RADIOLOGY - DX XR ERCP CATH BILIARY&PANCR S&I EACH 74330 $807.00 320 $564.90 $403.50 $645.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $166.00 65% of Billed Charges 65% of Billed Charges 32000523 RADIOLOGY - DX XR ESOPHAGUS EACH 74220 $455.00 320 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $70.02 $70.02 $90.96 65% of Billed Charges 65% of Billed Charges 32002669 RADIOLOGY - DX XR EYE FOREIGN BODY EACH 70030 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.42 65% of Billed Charges 65% of Billed Charges 32000572 RADIOLOGY - DX XR FACIAL BONES < 3 V EACH 70140 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.74 65% of Billed Charges 65% of Billed Charges 32002578 RADIOLOGY - DX XR FACIAL BONES < 3 V BIL EACH 70140 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.74 65% of Billed Charges 65% of Billed Charges 32002560 RADIOLOGY - DX XR FACIAL BONES < 3 V LT EACH 70140 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.74 65% of Billed Charges 65% of Billed Charges 32000564 RADIOLOGY - DX XR FACIAL BONES 3+V EACH 70150 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $43.35 65% of Billed Charges 65% of Billed Charges 32000580 RADIOLOGY - DX XR FEMUR 2+V RT EACH 73552 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $48.64 $48.64 $32.75 65% of Billed Charges 65% of Billed Charges 32002115 RADIOLOGY - DX XR FEMUR 2V+ BI EACH 73552 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $48.64 $48.64 $32.75 65% of Billed Charges 65% of Billed Charges 32002123 RADIOLOGY - DX XR FEMUR 2V+ LT EACH 73552 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $48.64 $48.64 $32.75 65% of Billed Charges 65% of Billed Charges 32002412 RADIOLOGY - DX XR FINGER(S) 2+V RT EACH 73140 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $33.80 65% of Billed Charges 65% of Billed Charges 32002255 RADIOLOGY - DX XR FINGER(S) 2+V BIL EACH 73140 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $33.80 65% of Billed Charges 65% of Billed Charges 32000598 RADIOLOGY - DX XR FINGER(S) 2+V LT EACH 73140 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $33.80 65% of Billed Charges 65% of Billed Charges 32000606 RADIOLOGY - DX XR FLUORO <1HR EACH 76000 $606.00 320 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $68.45 $68.45 $40.19 65% of Billed Charges 65% of Billed Charges 32000622 RADIOLOGY - DX XR FLUORO CV ACCESS PLACEMENT EACH 77001 $150.00 320 $105.00 $75.00 $120.00 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $91.18 65% of Billed Charges 65% of Billed Charges 32000648 RADIOLOGY - DX XR FLUORO NEEDLE PLACEMENT EACH 77002 $100.00 320 $70.00 $50.00 $80.00 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $102.37 65% of Billed Charges 65% of Billed Charges 32000663 RADIOLOGY - DX XR FOOT 2V BILAT EACH 73620 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $26.43 65% of Billed Charges 65% of Billed Charges 32000671 RADIOLOGY - DX XR FOOT 2V LT EACH 73620 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $26.43 65% of Billed Charges 65% of Billed Charges 32000655 RADIOLOGY - DX XR FOOT 2V RT EACH 73620 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $26.43 65% of Billed Charges 65% of Billed Charges 32000689 RADIOLOGY - DX XR FOOT CMPL 3+V BILAT EACH 73630 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.09 65% of Billed Charges 65% of Billed Charges 32000697 RADIOLOGY - DX XR FOOT CMPL 3+V LT EACH 73630 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.09 65% of Billed Charges 65% of Billed Charges 32000705 RADIOLOGY - DX XR FOOT CMPL 3+V RT EACH 73630 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.09 65% of Billed Charges 65% of Billed Charges 32001992 RADIOLOGY - DX XR FOREARM 2V BIL EACH 73090 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $27.43 65% of Billed Charges 65% of Billed Charges 32000713 RADIOLOGY - DX XR FOREARM 2V RT EACH 73090 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $27.43 65% of Billed Charges 65% of Billed Charges 32000721 RADIOLOGY - DX XR HAND 2 VIEWS RT EACH 73120 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $28.76 65% of Billed Charges 65% of Billed Charges 32002032 RADIOLOGY - DX XR HAND 2 VIEWS BIL EACH 73120 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $28.76 65% of Billed Charges 65% of Billed Charges 32002040 RADIOLOGY - DX XR HAND 2 VIEWS LT EACH 73120 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $28.76 65% of Billed Charges 65% of Billed Charges 32002057 RADIOLOGY - DX XR HAND CMPL 3+V BIL EACH 73130 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $33.09 65% of Billed Charges 65% of Billed Charges 32002065 RADIOLOGY - DX XR HAND CMPL 3+V LT EACH 73130 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $33.09 65% of Billed Charges 65% of Billed Charges 32000739 RADIOLOGY - DX XR HAND CMPL 3+V RT EACH 73130 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $33.09 65% of Billed Charges 65% of Billed Charges 32002099 RADIOLOGY - DX XR HIP CMPL 2+V UNI BIL EACH 73521 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $80.55 $80.55 $37.72 65% of Billed Charges 65% of Billed Charges 32002263 RADIOLOGY - DX XR HIP W/WO PELVIS 1 VIEW BI EACH 73501 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $48.64 $48.64 $30.08 65% of Billed Charges 65% of Billed Charges 32002081 RADIOLOGY - DX XR HIP W/WO PELVIS 1 VIEW LT EACH 73501 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $48.64 $48.64 $30.08 65% of Billed Charges 65% of Billed Charges 32000788 RADIOLOGY - DX XR HIP W/WO PELVIS 1 VIEW RT EACH 73501 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $48.64 $48.64 $30.08 65% of Billed Charges 65% of Billed Charges 32000796 RADIOLOGY - DX XR HIP W/WO PELVIS 2-3 V BI EACH 73522 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $80.55 $80.55 $49.00 65% of Billed Charges 65% of Billed Charges 32002107 RADIOLOGY - DX XR HIP W/WO PELVIS 2-3 V LT EACH 73502 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $48.64 $48.64 $42.72 65% of Billed Charges 65% of Billed Charges 32000747 RADIOLOGY - DX XR HIP W/WO PELVIS 2-3 V RT EACH 73502 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $48.64 $48.64 $42.72 65% of Billed Charges 65% of Billed Charges 32001968 RADIOLOGY - DX XR HUMERUS 2+V BIL EACH 73060 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.77 65% of Billed Charges 65% of Billed Charges 32001976 RADIOLOGY - DX XR HUMERUS 2+V LT EACH 73060 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.77 65% of Billed Charges 65% of Billed Charges 32000804 RADIOLOGY - DX XR HUMERUS 2+V RT EACH 73060 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.77 65% of Billed Charges 65% of Billed Charges 32303042 RADIOLOGY - DX XR HYSTEROSALPINGOGRAM S&I EACH 74740 $606.00 320 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $168.20 $168.20 $85.23 65% of Billed Charges 65% of Billed Charges 32000846 RADIOLOGY - DX XR KNEE 1-2V BILAT EACH 73560 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.77 65% of Billed Charges 65% of Billed Charges 32000853 RADIOLOGY - DX XR KNEE 1-2V LT EACH 73560 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.77 65% of Billed Charges 65% of Billed Charges 32000838 RADIOLOGY - DX XR KNEE 1-2V RT EACH 73560 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.77 65% of Billed Charges 65% of Billed Charges 32000887 RADIOLOGY - DX XR KNEE 3 VIEWS LT EACH 73562 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $37.09 65% of Billed Charges 65% of Billed Charges 32000861 RADIOLOGY - DX XR KNEE 3 VIEWS RT EACH 73562 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $37.09 65% of Billed Charges 65% of Billed Charges 32000879 RADIOLOGY - DX XR KNEE 3V BILAT EACH 73562 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $37.09 65% of Billed Charges 65% of Billed Charges 32000895 RADIOLOGY - DX XR KNEE AP STANDING BILATERAL EACH 73565 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $36.77 65% of Billed Charges 65% of Billed Charges 32002271 RADIOLOGY - DX XR KNEE AP STANDING LT EACH 73565 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $36.77 65% of Billed Charges 65% of Billed Charges 32002289 RADIOLOGY - DX XR KNEE AP STANDING RT EACH 73565 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $36.77 65% of Billed Charges 65% of Billed Charges 32002131 RADIOLOGY - DX XR KNEE CMPL 4+V BIL EACH 73564 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $41.39 65% of Billed Charges 65% of Billed Charges 32002149 RADIOLOGY - DX XR KNEE CMPL 4+V LT EACH 73564 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $41.39 65% of Billed Charges 65% of Billed Charges 32000903 RADIOLOGY - DX XR KNEE CMPL 4+V RT EACH 73564 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $41.39 65% of Billed Charges 65% of Billed Charges 32000937 RADIOLOGY - DX XR L-SPINE 4+V EACH 72110 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 Non Payable $45.69 65% of Billed Charges 65% of Billed Charges 32000945 RADIOLOGY - DX XR L-SPINE BENDING ONLY MIN 4V EACH 72120 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 Non Payable $37.38 65% of Billed Charges 65% of Billed Charges 32000952 RADIOLOGY - DX XR LUMBAR COMP W/BENDING VIEWS EACH 72114 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 Non Payable $55.99 65% of Billed Charges 65% of Billed Charges 32000960 RADIOLOGY - DX XR LUMBAR SPINE 2 OR 3 VIEWS EACH 72100 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $36.05 65% of Billed Charges 65% of Billed Charges 32000978 RADIOLOGY - DX XR LWR EXTREMITY INFANT 2+V BI EACH 73592 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $28.76 65% of Billed Charges 65% of Billed Charges 32000986 RADIOLOGY - DX XR LWR EXTREMITY INFANT 2+V LT EACH 73592 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $28.76 65% of Billed Charges 65% of Billed Charges 32000929 RADIOLOGY - DX XR LWR EXTREMITY INFANT 2+V RT EACH 73592 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $28.76 65% of Billed Charges 65% of Billed Charges 32001877 RADIOLOGY - DX XR MANDIBLE CMPL 4+V BIL EACH 70110 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $40.02 65% of Billed Charges 65% of Billed Charges 32001885 RADIOLOGY - DX XR MANDIBLE CMPL 4+V LT EACH 70110 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $40.02 65% of Billed Charges 65% of Billed Charges 32001000 RADIOLOGY - DX XR MANDIBLE CMPL 4+V RT EACH 70110 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $40.02 65% of Billed Charges 65% of Billed Charges 32001893 RADIOLOGY - DX XR MASTOIDS <3V BIL EACH 70120 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $34.75 65% of Billed Charges 65% of Billed Charges 32001026 RADIOLOGY - DX XR MASTOIDS <3V LT EACH 70120 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $34.75 65% of Billed Charges 65% of Billed Charges 32001018 RADIOLOGY - DX XR MASTOIDS <3V RT EACH 70120 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $34.75 65% of Billed Charges 65% of Billed Charges 32001901 RADIOLOGY - DX XR MASTOIDS CMPL 3+V BILAT EACH 70130 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $56.57 65% of Billed Charges 65% of Billed Charges 32001042 RADIOLOGY - DX XR MASTOIDS CMPL 3+V LT EACH 70130 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $56.57 65% of Billed Charges 65% of Billed Charges 32001034 RADIOLOGY - DX XR MASTOIDS CMPL 3+V RT EACH 70130 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $56.57 65% of Billed Charges 65% of Billed Charges 32302705 RADIOLOGY - DX XR MYELOGRAM >2 REGIONS S&I EACH 72270 "$1,980.00 " 320 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $389.66 Non Payable $134.14 65% of Billed Charges 65% of Billed Charges 32302671 RADIOLOGY - DX XR MYELOGRAM CERVICAL SPINE S& EACH 72240 "$1,980.00 " 320 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $389.66 Non Payable $105.57 65% of Billed Charges 65% of Billed Charges 32302697 RADIOLOGY - DX XR MYELOGRAM LUMBAR SPINE S&I EACH 72265 "$1,980.00 " 320 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $389.66 Non Payable $97.64 65% of Billed Charges 65% of Billed Charges 32302689 RADIOLOGY - DX XR MYELOGRAM THORACIC SP S&I EACH 72255 "$1,980.00 " 320 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $389.66 Non Payable $108.06 65% of Billed Charges 65% of Billed Charges 32001059 RADIOLOGY - DX XR NASAL CMPL 3+V EACH 70160 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $34.43 65% of Billed Charges 65% of Billed Charges 32001067 RADIOLOGY - DX XR NECK SOFT TISSUE EACH 70360 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.08 65% of Billed Charges 65% of Billed Charges 32002586 RADIOLOGY - DX XR ORBITS CMPL 4+V BIL EACH 70200 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $44.00 65% of Billed Charges 65% of Billed Charges 32002594 RADIOLOGY - DX XR ORBITS CMPL 4+V LT EACH 70200 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $44.00 65% of Billed Charges 65% of Billed Charges 32001109 RADIOLOGY - DX XR ORBITS CMPL 4+V RT EACH 70200 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $44.00 65% of Billed Charges 65% of Billed Charges 32001117 RADIOLOGY - DX XR ORTHOPANTOGRAM EACH 70355 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $18.38 65% of Billed Charges 65% of Billed Charges 32001133 RADIOLOGY - DX XR PELVIS & HIPS INF/CHILD 2+V EACH 73502 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $48.64 $48.64 $42.72 65% of Billed Charges 65% of Billed Charges 32001141 RADIOLOGY - DX XR PELVIS 1-2V EACH 72170 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $27.09 65% of Billed Charges 65% of Billed Charges 32001158 RADIOLOGY - DX XR PELVIS COMPLETE 3+ VIEWS EACH 72190 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $38.36 65% of Billed Charges 65% of Billed Charges 32001224 RADIOLOGY - DX XR REMOVE FB ESOPHAGUS S&I EACH 74235 $337.00 320 $235.90 $168.50 $269.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $166.11 65% of Billed Charges 65% of Billed Charges 32002610 RADIOLOGY - DX XR RIBS 2V UNI LT EACH 71100 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $33.71 65% of Billed Charges 65% of Billed Charges 32001232 RADIOLOGY - DX XR RIBS 2V UNI RT EACH 71100 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $33.71 65% of Billed Charges 65% of Billed Charges 32001240 RADIOLOGY - DX XR RIBS BILATERAL 3 VIEWS EACH 71110 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $40.65 65% of Billed Charges 65% of Billed Charges 32002628 RADIOLOGY - DX XR RIBS W/CXR 3+V UNI LT EACH 71101 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $38.67 65% of Billed Charges 65% of Billed Charges 32001265 RADIOLOGY - DX XR RIBS W/CXR 3+V UNI RT EACH 71101 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $38.67 65% of Billed Charges 65% of Billed Charges 32001273 RADIOLOGY - DX XR SACROILIAC JOINTS < 3 VIEWS EACH 72200 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $30.42 65% of Billed Charges 65% of Billed Charges 32001281 RADIOLOGY - DX XR SACROILIAC JOINTS 3+ VIEWS EACH 72202 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $36.04 65% of Billed Charges 65% of Billed Charges 32001299 RADIOLOGY - DX XR SACRUM/COCCYX 2+ VIEWS EACH 72220 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.76 65% of Billed Charges 65% of Billed Charges 32002198 RADIOLOGY - DX XR SALIVARY GLAND BIL EACH 70380 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $34.09 65% of Billed Charges 65% of Billed Charges 32002602 RADIOLOGY - DX XR SALIVARY GLAND LT EACH 70380 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $34.09 65% of Billed Charges 65% of Billed Charges 32001307 RADIOLOGY - DX XR SALIVARY GLAND RT EACH 70380 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $34.09 65% of Billed Charges 65% of Billed Charges 32002636 RADIOLOGY - DX XR SCAPULA CMPL BIL EACH 73010 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $26.42 65% of Billed Charges 65% of Billed Charges 32001927 RADIOLOGY - DX XR SCAPULA CMPL LT EACH 73010 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $26.42 65% of Billed Charges 65% of Billed Charges 32001315 RADIOLOGY - DX XR SCAPULA CMPL RT EACH 73010 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $26.42 65% of Billed Charges 65% of Billed Charges 32001331 RADIOLOGY - DX XR SELLA TURCICA EACH 70240 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $31.74 65% of Billed Charges 65% of Billed Charges 32001364 RADIOLOGY - DX XR SHOULDER 1 VIEW LT EACH 73020 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $20.43 65% of Billed Charges 65% of Billed Charges 32001356 RADIOLOGY - DX XR SHOULDER 1 VIEW RT EACH 73020 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $20.43 65% of Billed Charges 65% of Billed Charges 32001943 RADIOLOGY - DX XR SHOULDER CMPL 2+V BIL EACH 73030 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.41 65% of Billed Charges 65% of Billed Charges 32001950 RADIOLOGY - DX XR SHOULDER CMPL 2+V LT EACH 73030 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.41 65% of Billed Charges 65% of Billed Charges 32001372 RADIOLOGY - DX XR SHOULDER CMPL 2+V RT EACH 73030 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.41 65% of Billed Charges 65% of Billed Charges 32001935 RADIOLOGY - DX XR SHOULDER LTD 1VEW BIL EACH 73020 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $20.43 65% of Billed Charges 65% of Billed Charges 32303380 RADIOLOGY - DX XR SHUNTOGRAM NONVAS S&I EACH 75809 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 $60.18 $86.42 65% of Billed Charges 65% of Billed Charges 32302630 RADIOLOGY - DX XR SIALOGRAM S&I EACH 70390 $606.00 320 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $168.20 Non Payable $105.92 65% of Billed Charges 65% of Billed Charges 32001380 RADIOLOGY - DX XR SINUSES <3V EACH 70210 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $29.42 65% of Billed Charges 65% of Billed Charges 32001406 RADIOLOGY - DX XR SKULL CMPLL 4+V EACH 70260 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 Non Payable $41.66 65% of Billed Charges 65% of Billed Charges 32001414 RADIOLOGY - DX XR SKULL LTD <4V EACH 70250 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $33.75 65% of Billed Charges 65% of Billed Charges 32001422 RADIOLOGY - DX XR SMALL INTESTINE EACH 74250 $455.00 320 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $70.02 $70.02 $114.67 65% of Billed Charges 65% of Billed Charges 32001448 RADIOLOGY - DX XR SPINE 1 VIEW ANY LEVEL EACH 72020 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $23.09 65% of Billed Charges 65% of Billed Charges 32001463 RADIOLOGY - DX XR STERNOCLAVICULR JNT(S) 3+ V EACH 71130 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $37.72 65% of Billed Charges 65% of Billed Charges 32001471 RADIOLOGY - DX XR STERNUM 2+ VIEWS EACH 71120 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $31.06 65% of Billed Charges 65% of Billed Charges 40100125 RADIOLOGY - DX XR SURGICAL SPECIMEN EACH 76098 "$1,365.00 " 320 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $302.04 $302.04 $40.91 65% of Billed Charges 65% of Billed Charges 32001489 RADIOLOGY - DX XR SWALLOW CINE/VIDEO EACH 74230 $455.00 320 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $70.02 $70.02 $121.79 65% of Billed Charges 65% of Billed Charges 32001521 RADIOLOGY - DX XR THORACIC SPINE 2 VIEWS EACH 72070 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $30.06 65% of Billed Charges 65% of Billed Charges 32001539 RADIOLOGY - DX XR THORACIC SPINE 4+ VIEWS EACH 72074 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $40.69 65% of Billed Charges 65% of Billed Charges 32001547 RADIOLOGY - DX XR THORACOLUMBAR SPINE 2 VIEW EACH 72080 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $32.39 65% of Billed Charges 65% of Billed Charges 32002156 RADIOLOGY - DX XR TIBIA/FIBULA 2V BIL EACH 73590 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.10 65% of Billed Charges 65% of Billed Charges 32002164 RADIOLOGY - DX XR TIBIA/FIBULA 2V LT EACH 73590 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.10 65% of Billed Charges 65% of Billed Charges 32001554 RADIOLOGY - DX XR TIBIA/FIBULA 2V RT EACH 73590 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $29.10 65% of Billed Charges 65% of Billed Charges 32001562 RADIOLOGY - DX XR T-L-SPINE SCOLIOSIS 2-3 V EACH 72082 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $80.55 Non Payable $63.94 65% of Billed Charges 65% of Billed Charges 32001570 RADIOLOGY - DX XR TMJ OPEN & CLSD BILAT EACH 70330 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $48.71 65% of Billed Charges 65% of Billed Charges 32002354 RADIOLOGY - DX XR TOE(S) 2+V BIL EACH 73660 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $26.79 65% of Billed Charges 65% of Billed Charges 32002461 RADIOLOGY - DX XR TOE(S) 2+V LT EACH 73660 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $26.79 65% of Billed Charges 65% of Billed Charges 32001596 RADIOLOGY - DX XR TOE(S) 2+V RT EACH 73660 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $26.79 65% of Billed Charges 65% of Billed Charges 32001620 RADIOLOGY - DX XR TOMOGRAM SINGLE PLANE EACH 76100 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $60.18 $60.18 $92.87 65% of Billed Charges 65% of Billed Charges 32303596 RADIOLOGY - DX XR TRANSCATH ANGIO EXIST CATH EACH 75898 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges $60.18 $60.18 "$1,546.19 " 65% of Billed Charges 65% of Billed Charges 32303794 RADIOLOGY - DX XR TRANSCATH BIOPSY S&I EACH 75970 "$1,850.00 " 320 "$1,295.00 " $925.00 "$1,480.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $435.46 65% of Billed Charges 65% of Billed Charges 32303570 RADIOLOGY - DX XR TRANSCATH EMBOLIZATION S&I EACH 75894 "$2,580.69 " 320 "$1,806.48 " "$1,290.35 " "$2,064.55 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable "$1,015.14 " 65% of Billed Charges 65% of Billed Charges 32001638 RADIOLOGY - DX XR T-SPINE 3V EACH 72072 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 Non Payable $36.37 65% of Billed Charges 65% of Billed Charges 32001661 RADIOLOGY - DX XR UGI W/AIR W/SMALL BOWEL EACH 74246 $455.00 320 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $70.02 $70.02 $130.94 65% of Billed Charges 65% of Billed Charges 32003089 RADIOLOGY - DX XR UPPER EXT CHILD 1 VIEW LT EACH 73090 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $27.43 65% of Billed Charges 65% of Billed Charges 32001745 RADIOLOGY - DX XR UPR EXT INFANT 2+V BIL EACH 73092 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $28.76 65% of Billed Charges 65% of Billed Charges 32001737 RADIOLOGY - DX XR UPR EXT INFANT 2+V LT EACH 73092 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $28.76 65% of Billed Charges 65% of Billed Charges 32001752 RADIOLOGY - DX XR UPR EXT INFANT 2+V RT EACH 73092 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $28.76 65% of Billed Charges 65% of Billed Charges 32001760 RADIOLOGY - DX XR UROGRAM (IVP) EACH 74400 $455.00 320 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $137.30 $137.30 $120.50 65% of Billed Charges 65% of Billed Charges 32302937 RADIOLOGY - DX XR UROGRAM ANTEGRADE S&I EACH 74425 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $137.30 $137.30 $122.48 65% of Billed Charges 65% of Billed Charges 32001786 RADIOLOGY - DX XR UROGRAM RETROGRADE EACH 74420 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $137.30 $137.30 $69.74 65% of Billed Charges 65% of Billed Charges 32001794 RADIOLOGY - DX XR UROGRAM W/NEPHROTOMOGRAM EACH 74415 $455.00 320 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $137.30 $137.30 $143.19 65% of Billed Charges 65% of Billed Charges 32303422 RADIOLOGY - DX XR VENACAVAGRAM INFERIOR S&I EACH 75825 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $120.96 65% of Billed Charges 65% of Billed Charges 32303430 RADIOLOGY - DX XR VENACAVAGRAM SUPERIOR S&I EACH 75827 "$3,960.00 " 320 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $125.91 65% of Billed Charges 65% of Billed Charges 32303554 RADIOLOGY - DX XR VENOGR HEPATIC WO HEMO S&I EACH 75891 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $129.98 65% of Billed Charges 65% of Billed Charges 32303471 RADIOLOGY - DX XR VENOGRAM ADRENAL BILAT S&I EACH 75842 "$13,588.00 " 320 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $162.85 65% of Billed Charges 65% of Billed Charges 32303463 RADIOLOGY - DX XR VENOGRAM ADRENAL UNI S&I EACH 75840 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $133.05 65% of Billed Charges 65% of Billed Charges 32303414 RADIOLOGY - DX XR VENOGRAM EXTREMITY BI S&I EACH 75822 "$3,960.00 " 320 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $120.54 65% of Billed Charges 65% of Billed Charges 32303406 RADIOLOGY - DX XR VENOGRAM EXTREMITY UNI S&I EACH 75820 "$3,960.00 " 320 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $102.71 65% of Billed Charges 65% of Billed Charges 32303547 RADIOLOGY - DX XR VENOGRAM HEPATIC W/HEMO EACH 75889 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $127.98 65% of Billed Charges 65% of Billed Charges 32304529 RADIOLOGY - DX XR VENOGRAM RENAL UNI S&I EACH 75831 "$7,882.00 " 770 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 32002016 RADIOLOGY - DX XR WRIST 2V BIL EACH 73100 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.10 65% of Billed Charges 65% of Billed Charges 32002024 RADIOLOGY - DX XR WRIST 2V LT EACH 73100 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.10 65% of Billed Charges 65% of Billed Charges 32001802 RADIOLOGY - DX XR WRIST 2V RT EACH 73100 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $31.10 65% of Billed Charges 65% of Billed Charges 32001810 RADIOLOGY - DX XR WRIST CMPL 3+V BI EACH 73110 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $36.76 65% of Billed Charges 65% of Billed Charges 32001828 RADIOLOGY - DX XR WRIST CMPL 3+V LT EACH 73110 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $36.76 65% of Billed Charges 65% of Billed Charges 32001836 RADIOLOGY - DX XR WRIST CMPL 3+V RT EACH 73110 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $36.76 65% of Billed Charges 65% of Billed Charges 32308884 RADIOLOGY - DX X-RAY BILE DUCT DILATION EACH 74363 $124.00 320 $86.80 $62.00 $99.20 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $122.31 65% of Billed Charges 65% of Billed Charges 32308827 RADIOLOGY - DX X-RAY BILE DUCT ENDOSCOPY EACH 74328 "$1,042.00 " 320 $729.40 $521.00 $833.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $115.93 65% of Billed Charges 65% of Billed Charges 32003048 RADIOLOGY - DX X-RAY EXAM ABDOMEN 1 VIEW EACH 74018 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $49.69 $49.69 $27.74 65% of Billed Charges 65% of Billed Charges 32003055 RADIOLOGY - DX X-RAY EXAM ABDOMEN 2 VIEWS EACH 74019 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $94.99 $94.99 $34.04 65% of Billed Charges 65% of Billed Charges 32003063 RADIOLOGY - DX X-RAY EXAM ABDOMEN 3+ VIEWS EACH 74021 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $94.99 $94.99 $39.34 65% of Billed Charges 65% of Billed Charges 32003006 RADIOLOGY - DX X-RAY EXAM CHEST 1 VIEW EACH 71045 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $49.69 Non Payable $24.41 65% of Billed Charges 65% of Billed Charges 32003014 RADIOLOGY - DX X-RAY EXAM CHEST 2 VIEWS EACH 71046 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $49.69 Non Payable $31.04 65% of Billed Charges 65% of Billed Charges 32003022 RADIOLOGY - DX X-RAY EXAM CHEST 3 VIEWS EACH 71047 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $49.69 Non Payable $39.00 65% of Billed Charges 65% of Billed Charges 32003030 RADIOLOGY - DX X-RAY EXAM CHEST 4+ VIEWS EACH 71048 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $94.99 Non Payable $42.30 65% of Billed Charges 65% of Billed Charges 32308926 RADIOLOGY - DX X-RAY EXAM OF KIDNEY LESION EACH 74470 "$1,365.00 " 320 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $168.20 $168.20 $453.30 65% of Billed Charges 65% of Billed Charges 32308918 RADIOLOGY - DX X-RAY EXAM OF PENIS EACH 74445 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $137.30 $137.30 $118.91 65% of Billed Charges 65% of Billed Charges 32308942 RADIOLOGY - DX X-RAY EXAM OF PERINEUM EACH 74775 $606.00 320 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $137.30 $137.30 $225.37 65% of Billed Charges 65% of Billed Charges 32308785 RADIOLOGY - DX X-RAY EXAM OF PERITONEUM EACH 74190 "$1,365.00 " 320 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $168.20 $168.20 $452.30 65% of Billed Charges 65% of Billed Charges 32308793 RADIOLOGY - DX X-RAY EXAM OF PERITONEUM EACH 74190 "$1,365.00 " 320 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $168.20 $168.20 $452.30 65% of Billed Charges 65% of Billed Charges 32308595 RADIOLOGY - DX X-RAY EXAM OF TEAR DUCT EACH 70170 $606.00 510 $424.20 $303.00 $484.80 65% 80% 50% 50% 65% Non Payable Non Payable 32308934 RADIOLOGY - DX X-RAY FALLOPIAN TUBE EACH 74742 $224.00 320 $156.80 $112.00 $179.20 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $85.54 65% of Billed Charges 65% of Billed Charges 32308835 RADIOLOGY - DX X-RAY FOR PANCREAS ENDOSCOPY EACH 74329 $850.00 320 $595.00 $425.00 $680.00 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $99.08 65% of Billed Charges 65% of Billed Charges 32308843 RADIOLOGY - DX X-RAY GUIDE FOR GI TUBE EACH 74340 $99.00 320 $69.30 $49.50 $79.20 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $106.41 65% of Billed Charges 65% of Billed Charges 32308876 RADIOLOGY - DX X-RAY GUIDE GI DILATION EACH 74360 $78.00 320 $54.60 $39.00 $62.40 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $115.58 65% of Billed Charges 65% of Billed Charges 32308868 RADIOLOGY - DX X-RAY GUIDE INTESTINAL TUBE EACH 74355 $99.00 320 $69.30 $49.50 $79.20 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $139.61 65% of Billed Charges 65% of Billed Charges 32003071 RADIOLOGY - DX X-RAY NOSE TO RECTUM FOR FB EACH 76010 $225.00 320 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $35.92 $35.92 $27.41 65% of Billed Charges 65% of Billed Charges 32308611 RADIOLOGY - DX X-RAY OF LOWER SPINE DISK EACH 72295 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307324 RADIOLOGY - IR ABD PARACENTESIS EACH 49082 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307332 RADIOLOGY - IR ABD PARACENTESIS W/IMAGING EACH 49083 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309841 RADIOLOGY - IR ABLAT RENAL TUM PERC CRYO EACH 50593 "$25,452.00 " 510 "$17,816.40 " "$12,726.00 " "$20,361.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305377 RADIOLOGY - IR ABLATE BONE TUMOR(S) CRYO EACH 20983 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305369 RADIOLOGY - IR ABLATE BONE TUMOR(S) RADIOFREQ EACH 20982 "$32,541.00 " 510 "$22,778.70 " "$16,270.50 " "$26,032.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32313322 RADIOLOGY - IR ADJUST TUN IP CATH PERC EACH 49999 "$2,242.00 " 361 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case $897 $815 Non Payable "$1,266 " "$1,266 " 32307373 RADIOLOGY - IR AIR INJECTION INTO ABDOMEN EACH 49400 $274.00 510 $191.80 $137.00 $219.20 65% 80% 50% 50% 65% Non Payable Non Payable 32306532 RADIOLOGY - IR ARTERIAL CATHETERIZATION EACH 36620 $151.00 510 $105.70 $75.50 $120.80 65% 80% 50% 50% 65% Non Payable Non Payable 32300154 RADIOLOGY - IR ARTHROCENT ASP/INJ JT INTERMED EACH 20605 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 32300147 RADIOLOGY - IR ARTHROCENT ASP/INJ JT SMALL EACH 20600 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 32300022 RADIOLOGY - IR ASP CYST BREAST EACH 19000 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32300030 RADIOLOGY - IR ASP CYST BREAST EA ADD EACH 19001 $260.00 510 $182.00 $130.00 $208.00 65% 80% 50% 50% 65% Non Payable Non Payable 32307720 RADIOLOGY - IR ASP/INJ CYST RENAL PERC EACH 50390 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32302408 RADIOLOGY - IR ASPIRAT/INJECT CYST THYROID EACH 60300 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304867 RADIOLOGY - IR AV FISTULA GRAFT DECLOT EACH 36904 "$14,132.00 " 510 "$9,892.40 " "$7,066.00 " "$11,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304875 RADIOLOGY - IR AV FISTULA GRFT DECLOT W/ANGIO EACH 36905 "$27,201.00 " 510 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304883 RADIOLOGY - IR AV FISTULA GRFT DECLOT W/STENT EACH 36906 "$43,356.00 " 510 "$30,349.20 " "$21,678.00 " "$34,684.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306565 RADIOLOGY - IR AV FISTULA REVISION OPEN EACH 36832 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309940 RADIOLOGY - IR BALLON ANGIOP CTR DIALYSIS SEG EACH 36907 "$3,015.00 " 323 "$2,110.50 " "$1,507.50 " "$2,412.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $160.38 65% of Billed Charges 65% of Billed Charges 32309825 RADIOLOGY - IR BALLOON DILATION URETER EACH 50706 "$2,805.00 " 320 "$1,963.50 " "$1,402.50 " "$2,244.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $190.80 65% of Billed Charges 65% of Billed Charges 32307290 RADIOLOGY - IR BILIARY ENDO W/DILATE W/STENT EACH 47556 "$25,452.00 " 510 "$17,816.40 " "$12,726.00 " "$20,361.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307282 RADIOLOGY - IR BILIARY ENDO W/DILATE WO STENT EACH 47555 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307274 RADIOLOGY - IR BILIARY ENDOSCOPY WO DILATION EACH 47552 "$18,706.00 " 510 "$13,094.20 " "$9,353.00 " "$14,964.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307357 RADIOLOGY - IR BIOPSY ABDOMINAL MASS EACH 49180 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309387 RADIOLOGY - IR BIOPSY OF HEART LINING EACH 93505 "$7,882.00 " 480 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 32305385 RADIOLOGY - IR BIOPSY OF NECK/CHEST EACH 21550 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301574 RADIOLOGY - IR BIOPSY TRANSCATHETER EACH 37200 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306987 RADIOLOGY - IR BONE MARROW ASPIRATION ONLY EACH 38220 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305609 RADIOLOGY - IR BRONCHOSCOPY DILATE W/STENT EACH 31631 "$16,923.00 " 510 "$11,846.10 " "$8,461.50 " "$13,538.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305591 RADIOLOGY - IR BRONCHOSCOPY W/BIOPSY(S) EACH 31625 "$4,197.00 " 510 "$2,937.90 " "$2,098.50 " "$3,357.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306995 RADIOLOGY - IR BX BONE MARROW NEEDLE EACH 38221 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32300105 RADIOLOGY - IR BX BONE NEEDLE DEEP EACH 20225 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32300097 RADIOLOGY - IR BX BONE NEEDLE SUPERFIC EACH 20220 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301731 RADIOLOGY - IR BX GLAND SALIVARY INCISIONAL EACH 42405 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301723 RADIOLOGY - IR BX GLAND SALIVARY NEEDLE EACH 42400 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301772 RADIOLOGY - IR BX LIVER NEEDLE PERC EACH 47000 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301780 RADIOLOGY - IR BX LIVER W/PROC EACH 47001 $215.93 510 $151.15 $107.97 $172.74 65% 80% 50% 50% 65% Non Payable Non Payable 32300345 RADIOLOGY - IR BX LUNG/MEDIASTINUM PERC NDL EACH 32408 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304040 RADIOLOGY - IR BX MUSCLE DEEP EACH 20205 "$7,026.00 " 510 "$4,918.20 " "$3,513.00 " "$5,620.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304032 RADIOLOGY - IR BX MUSCLE SUPERFICIAL EACH 20200 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301962 RADIOLOGY - IR BX PANCREAS NEEDLE PERC EACH 48102 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32300337 RADIOLOGY - IR BX PLEURA NEEDLE PERC EACH 32400 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305401 RADIOLOGY - IR BX SOFT TISSUE BACK DEEP EACH 21925 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305393 RADIOLOGY - IR BX SOFT TISSUE BACK SUPERFCIAL EACH 21920 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304057 RADIOLOGY - IR BX THYROID PERC EACH 60100 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301699 RADIOLOGY - IR BX/EXC LMPH NODE SUPER NDL EACH 38505 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306581 RADIOLOGY - IR CANNULA DECLOTTING EACH 36861 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32302341 RADIOLOGY - IR CATH/INTRO CONTRAST HYSTEROSAL EACH 58340 $198.00 510 $138.60 $99.00 $158.40 65% 80% 50% 50% 65% Non Payable Non Payable 32307506 RADIOLOGY - IR CHANGE G-TUBE TO G-J PERC EACH 49446 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309585 RADIOLOGY - IR CHANGE URETER STENT PERC EACH 50382 "$5,037.00 " 320 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $267.65 65% of Billed Charges 65% of Billed Charges 32302150 RADIOLOGY - IR CHG TUBE URETEROSTOMY EACH 50688 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301855 RADIOLOGY - IR CHOLECYSTOSTOMY PERC EACH 47490 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309163 RADIOLOGY - IR CINE/VIDEO X-RAYS EACH 76120 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $68.45 $68.45 $102.86 65% of Billed Charges 65% of Billed Charges 32306508 RADIOLOGY - IR COLLECT BLOOD VENOUS CATHETER EACH 36592 $316.00 510 $221.20 $158.00 $252.80 65% 80% 50% 50% 65% Non Payable Non Payable 32308900 RADIOLOGY - IR CONTRAST X-RAY BLADDER EACH 74430 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $137.30 $137.30 $37.95 65% of Billed Charges 65% of Billed Charges 32308587 RADIOLOGY - IR CONTRAST X-RAY OF BRAIN EACH 70015 "$1,980.00 " 510 "$1,386.00 " $990.00 "$1,584.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307175 RADIOLOGY - IR CONVERSION EXT BIL DRG CATH EACH 47535 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309171 RADIOLOGY - IR CT 3D RENDERING W/POSTPROCESS EACH 76377 $466.00 350 $326.20 $233.00 $372.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $77.12 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 32309965 RADIOLOGY - IR CT CERVICAL SPINE W/CONT (IR) EACH 72126 $951.00 350 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $237.62 $237.62 $207.08 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 32309312 RADIOLOGY - IR CT GUIDED NEEDLE PLACEMENT EACH 77012 "$1,100.00 " 350 $770.00 $550.00 $880.00 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $161.21 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 32309338 RADIOLOGY - IR CT GUIDED TISSUE ABLATION EACH 77013 $877.00 350 $613.90 $438.50 $701.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $581.78 $500 each paid in addition to other neg. rates $500 each paid in addition to other neg. rates 32306516 RADIOLOGY - IR DECLOT VASCULAR DEVICE EACH 36593 $838.00 510 $586.60 $419.00 $670.40 65% 80% 50% 50% 65% Non Payable Non Payable 32302531 RADIOLOGY - IR DECOMP DISK LUMBAR PERC EACH 62287 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32308504 RADIOLOGY - IR DESTROY C/TH FACET JNT ADDL EACH 64634 $748.00 510 $523.60 $374.00 $598.40 65% 80% 50% 50% 65% Non Payable Non Payable 32308488 RADIOLOGY - IR DESTROY CERV/THOR FACET JNT EACH 64633 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32308546 RADIOLOGY - IR DESTROY L/S FACET JNT ADDL EACH 64636 $325.00 510 $227.50 $162.50 $260.00 65% 80% 50% 50% 65% Non Payable Non Payable 32308520 RADIOLOGY - IR DESTROY LUMB/SAC FACET JNT EACH 64635 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307241 RADIOLOGY - IR DILATE BILIARY DUCT/AMPULLA EACH 47542 $450.00 510 $315.00 $225.00 $360.00 65% 80% 50% 50% 65% Non Payable Non Payable 32307068 RADIOLOGY - IR DILATE ESOPHAGUS EACH 43453 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307845 RADIOLOGY - IR DILATE IC VASOSPASM ADDL DIFF EACH 61642 $818.00 510 $572.60 $409.00 $654.40 65% 80% 50% 50% 65% Non Payable Non Payable 32307837 RADIOLOGY - IR DILATE IC VASOSPASM ADDL SAME EACH 61641 $818.00 510 $572.60 $409.00 $654.40 65% 80% 50% 50% 65% Non Payable Non Payable 32307829 RADIOLOGY - IR DILATE IC VASOSPASM INIT EACH 61640 "$1,629.00 " 510 "$1,140.30 " $814.50 "$1,303.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32308603 RADIOLOGY - IR DISCOGRAPHY CERV/THOR SPINE EACH 72285 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309361 RADIOLOGY - IR DISSOLVE CLOT HEART VESSEL EACH 92977 $838.00 480 $586.60 $419.00 $670.40 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 32303919 RADIOLOGY - IR DOPPLER ARTERIAL EXT EACH 93922 $316.00 921 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 32305054 RADIOLOGY - IR DRAIN BY CATH SOFT TISSUE EACH 10030 "$1,740.00 " 320 "$1,218.00 " $870.00 "$1,392.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $131.17 65% of Billed Charges 65% of Billed Charges 32307860 RADIOLOGY - IR DRAIN SPINAL CORD CYST EACH 62268 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307316 RADIOLOGY - IR DRAINAGE OF ABDOMEN EACH 48000 "$5,410.00 " 510 "$3,787.00 " "$2,705.00 " "$4,328.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32300766 RADIOLOGY - IR E/V PL DVC OCCL ART ILIAC EACH 34808 "$2,623.00 " 360 "$1,836.10 " "$1,311.50 " "$2,098.40 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case $319 $290 $231.88 "$1,266 " "$1,266 " 32300667 RADIOLOGY - IR E/V RPR TAA + THOR AORT EXT EACH 33880 "$5,419.62 " 360 "$3,793.73 " "$2,709.81 " "$4,335.70 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case $319 $290 "$2,050.71 " "$1,266 " "$1,266 " 32307258 RADIOLOGY - IR ENDOLUMINAL BX BILIARY TREE EACH 47543 $450.00 510 $315.00 $225.00 $360.00 65% 80% 50% 50% 65% Non Payable Non Payable 32305781 RADIOLOGY - IR ENDOVASC PROSTH DELAYED EACH 33886 "$9,024.00 " 510 "$6,316.80 " "$4,512.00 " "$7,219.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305773 RADIOLOGY - IR ENDOVASC PROSTH TAA ADD-ON EACH 33884 "$9,024.00 " 510 "$6,316.80 " "$4,512.00 " "$7,219.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305757 RADIOLOGY - IR ENDOVASC TAA REPR W/O SUBCL EACH 33881 "$9,024.00 " 510 "$6,316.80 " "$4,512.00 " "$7,219.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307795 RADIOLOGY - IR ENDOVASC TEMPRY VESSEL OCCL EACH 61623 "$27,201.00 " 510 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305831 RADIOLOGY - IR ENDOVASC VISC AORTA 1 GRAFT EACH 34841 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305849 RADIOLOGY - IR ENDOVASC VISC AORTA 2 GRAFT EACH 34842 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305856 RADIOLOGY - IR ENDOVASC VISC AORTA 3 GRAFT EACH 34843 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305864 RADIOLOGY - IR ENDOVASC VISC AORTA 4 GRAFT EACH 34844 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306441 RADIOLOGY - IR ENDOVENOUS LASER 1ST VEIN EACH 36478 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306466 RADIOLOGY - IR ENDOVENOUS LASER VEIN ADDON EACH 36479 $213.00 510 $149.10 $106.50 $170.40 65% 80% 50% 50% 65% Non Payable Non Payable 32306409 RADIOLOGY - IR ENDOVENOUS RF 1ST VEIN EACH 36475 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306425 RADIOLOGY - IR ENDOVENOUS RF VEIN ADD-ON EACH 36476 "$1,431.00 " 510 "$1,001.70 " $715.50 "$1,144.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307043 RADIOLOGY - IR ESOPH ENDOSCOPY DILATION EACH 43220 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307035 RADIOLOGY - IR ESOPHAGUS ENDOSCOPY EACH 43215 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309510 RADIOLOGY - IR EVASC PRLNG ADMN RX AGNT 1ST EACH 61650 "$1,629.00 " 510 "$1,140.30 " $814.50 "$1,303.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309528 RADIOLOGY - IR EVASC PRLNG ADMN RX AGNT ADD EACH 61651 "$1,629.00 " 510 "$1,140.30 " $814.50 "$1,303.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305096 RADIOLOGY - IR EXC LESN MAL SCALP/HND 1.1-2.0 EACH 11622 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307183 RADIOLOGY - IR EXCHANGE BILIARY DRG CATH EACH 47536 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309726 RADIOLOGY - IR EXCHANGE NEP CATH EACH 50435 "$5,037.00 " 320 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $102.92 65% of Billed Charges 65% of Billed Charges 32302028 RADIOLOGY - IR EXCHG CATH ABSC/CYST DRAIN EACH 49423 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306573 RADIOLOGY - IR EXTERNAL CANNULA DECLOTTING EACH 36860 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304370 RADIOLOGY - IR FEM/POP REVASC W/ATHERECT EACH 37225 "$43,356.00 " 360 "$30,349.20 " "$21,678.00 " "$34,684.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $686.36 "$1,266 " "$1,266 " 32304388 RADIOLOGY - IR FEM/POP REVASC W/STENT EACH 37226 "$27,201.00 " 360 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $593.58 "$1,266 " "$1,266 " 32304396 RADIOLOGY - IR FEM/POP REVASC W/STENT&ATHER EACH 37227 "$43,356.00 " 360 "$30,349.20 " "$21,678.00 " "$34,684.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$2,695 " "$2,450 " $826.50 "$1,266 " "$1,266 " 32304362 RADIOLOGY - IR FEM/POP REVASC W/TLA EACH 37224 "$14,132.00 " 360 "$9,892.40 " "$7,066.00 " "$11,305.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,672 " "$1,520 " $507.09 "$1,266 " "$1,266 " 32307548 RADIOLOGY - IR FIX G/COLON TUBE W/DEVICE EACH 49460 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307555 RADIOLOGY - IR FLUORO EXAM OF G/COLON TUBE EACH 49465 $606.00 510 $424.20 $303.00 $484.80 65% 80% 50% 50% 65% Non Payable Non Payable 32305070 RADIOLOGY - IR I&D HEMATOMA/SEROMA/FLUID EACH 10140 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305799 RADIOLOGY - IR IABP INSERTION EACH 33967 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306730 RADIOLOGY - IR ILIAC REVASC ADDL VESSEL W/ EACH 37222 $360.00 360 $252.00 $180.00 $288.00 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,672 " "$1,520 " $213.09 Non Payable Non Payable 32306763 RADIOLOGY - IR ILIAC REVASC ADDL VESSEL W/ EACH 37223 $360.00 360 $252.00 $180.00 $288.00 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,672 " "$1,520 " $242.93 Non Payable Non Payable 32304347 RADIOLOGY - IR ILIAC REVASC W/STENT EACH 37221 "$27,201.00 " 360 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $563.83 "$1,266 " "$1,266 " 32304339 RADIOLOGY - IR ILIAC REVASC W/TLA INIT VESSEL EACH 37220 "$14,132.00 " 360 "$9,892.40 " "$7,066.00 " "$11,305.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,672 " "$1,520 " $457.30 "$1,266 " "$1,266 " 32307381 RADIOLOGY - IR IMAGE CATH FLUID COLXN VISC EACH 49405 "$4,009.00 " 320 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $198.57 65% of Billed Charges 65% of Billed Charges 32307399 RADIOLOGY - IR IMAGE CATH FLUID PERI/RETRO EACH 49406 "$4,009.00 " 320 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $197.95 65% of Billed Charges 65% of Billed Charges 32307407 RADIOLOGY - IR IMAGE CATH FLUID TRNS/VGNL EACH 49407 "$4,009.00 " 320 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $211.47 65% of Billed Charges 65% of Billed Charges 32308009 RADIOLOGY - IR IMPLANT ELECTRODE - 1 LEAD EACH 63650 "$16,910.00 " 510 "$11,837.00 " "$8,455.00 " "$13,528.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307993 RADIOLOGY - IR IMPLANT/REV INTRA/EPI CATHETER EACH 62350 "$16,471.00 " 320 "$11,529.70 " "$8,235.50 " "$13,176.80 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $407.19 65% of Billed Charges 65% of Billed Charges 32308462 RADIOLOGY - IR INJ ANES CELIAC PLEXUS EACH 64530 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32308421 RADIOLOGY - IR INJ ANES GANGL SPHENOPALAT EACH 64505 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 32308447 RADIOLOGY - IR INJ ANES LUMBAR/THORACIC EACH 64520 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304131 RADIOLOGY - IR INJ ANES NERVE TRIGEMINAL EACH 64400 $733.00 361 $513.10 $366.50 $586.40 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case $88 $80 $52.30 $824 $824 32308322 RADIOLOGY - IR INJ ANES/STER CERV/THOR ADD EACH 64491 $663.00 510 $464.10 $331.50 $530.40 65% 80% 50% 50% 65% Non Payable Non Payable 32308306 RADIOLOGY - IR INJ ANES/STER CERV/THOR SGL EACH 64490 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32308389 RADIOLOGY - IR INJ ANES/STER LUMB/SACR ADD EACH 64494 $452.00 510 $316.40 $226.00 $361.60 65% 80% 50% 50% 65% Non Payable Non Payable 32308363 RADIOLOGY - IR INJ ANES/STER LUMB/SACR SGL EACH 64493 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32303935 RADIOLOGY - IR INJ ARTHRO SACROILIAC W/O ANES EACH 27096 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32300287 RADIOLOGY - IR INJ ARTHROGRAM ANKLE EACH 27648 $760.00 510 $532.00 $380.00 $608.00 65% 80% 50% 50% 65% Non Payable Non Payable 32300261 RADIOLOGY - IR INJ ARTHROGRAM HIP ANES EACH 27095 $760.00 510 $532.00 $380.00 $608.00 65% 80% 50% 50% 65% Non Payable Non Payable 32300220 RADIOLOGY - IR INJ ARTHROGRAM SHOULDER EACH 23350 $760.00 510 $532.00 $380.00 $608.00 65% 80% 50% 50% 65% Non Payable Non Payable 32300246 RADIOLOGY - IR INJ ARTHROGRAM WRIST EACH 25246 $760.00 510 $532.00 $380.00 $608.00 65% 80% 50% 50% 65% Non Payable Non Payable 32302564 RADIOLOGY - IR INJ CHEMONUCLEOLYSIS LUMB EACH 62292 "$4,774.00 " 510 "$3,341.80 " "$2,387.00 " "$3,819.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307134 RADIOLOGY - IR INJ CHOLANGIOGRAM EXIST ACCESS EACH 47531 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307142 RADIOLOGY - IR INJ CHOLANGIOGRAM NEW ACCESS EACH 47532 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301566 RADIOLOGY - IR INJ CONTR W/FLUORO EVAL CV DEV EACH 36598 $530.00 510 $371.00 $265.00 $424.00 65% 80% 50% 50% 65% Non Payable Non Payable 32302036 RADIOLOGY - IR INJ CONTRAST ABSC/CYST EACH 49424 $173.00 510 $121.10 $86.50 $138.40 65% 80% 50% 50% 65% Non Payable Non Payable 32307878 RADIOLOGY - IR INJ EPIDURAL BLOOD/CLOT PATCH EACH 62273 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32302523 RADIOLOGY - IR INJ MYELOGRAM/CT SCAN SPINAL EACH 62284 $450.00 510 $315.00 $225.00 $360.00 65% 80% 50% 50% 65% Non Payable Non Payable 32309684 RADIOLOGY - IR INJ NEPH/URETEROGRM EXT ACC EACH 50431 "$1,689.00 " 320 "$1,182.30 " $844.50 "$1,351.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $67.05 65% of Billed Charges 65% of Billed Charges 32309668 RADIOLOGY - IR INJ NEPH/URETEROGRM NEW ACC EACH 50430 "$1,689.00 " 320 "$1,182.30 " $844.50 "$1,351.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $160.39 65% of Billed Charges 65% of Billed Charges 32307886 RADIOLOGY - IR INJ NEUROLYTIC CERV/THOR EACH 62281 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307894 RADIOLOGY - IR INJ NEUROLYTIC LUMB/CAUD EACH 62282 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32302572 RADIOLOGY - IR INJ OCCLUS ART A/V MALFORM EACH 62294 "$2,254.00 " 510 "$1,577.80 " "$1,127.00 " "$1,803.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32308348 RADIOLOGY - IR INJ PARAVERT F JT C/T 3 LEV EACH 64492 $461.00 510 $322.70 $230.50 $368.80 65% 80% 50% 50% 65% Non Payable Non Payable 32308405 RADIOLOGY - IR INJ PARAVERT F JT L/S 3 LEV EACH 64495 $461.00 510 $322.70 $230.50 $368.80 65% 80% 50% 50% 65% Non Payable Non Payable 32301707 RADIOLOGY - IR INJ RA TRACER ID SENTINL NODE EACH 38792 "$1,020.00 " 510 $714.00 $510.00 $816.00 65% 80% 50% 50% 65% Non Payable Non Payable 32302044 RADIOLOGY - IR INJ SHUNT PRE-PLACED EACH 49427 $88.01 510 $61.61 $44.01 $70.41 65% 80% 50% 50% 65% Non Payable Non Payable 32301749 RADIOLOGY - IR INJ SIALOGRAM EACH 42550 $261.00 510 $182.70 $130.50 $208.80 65% 80% 50% 50% 65% Non Payable Non Payable 32305161 RADIOLOGY - IR INJ SINGLE TENDON/LIGAMENT EACH 20550 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 32307910 RADIOLOGY - IR "INJ SPINE DISK, XRAY CERV/THOR" EACH 62291 $261.00 320 $182.70 $130.50 $208.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $157.16 65% of Billed Charges 65% of Billed Charges 32307902 RADIOLOGY - IR "INJ SPINE DISK, XRAY LUMBAR " EACH 62290 $261.00 320 $182.70 $130.50 $208.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $164.69 65% of Billed Charges 65% of Billed Charges 32300121 RADIOLOGY - IR INJ TRACT SINOGRAM EACH 20501 $440.00 510 $308.00 $220.00 $352.00 65% 80% 50% 50% 65% Non Payable Non Payable 32305203 RADIOLOGY - IR INJ TRIGGER PT 1-2 MUSCLE(S) EACH 20552 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 32305211 RADIOLOGY - IR INJ TRIGGER PT 3 OR > MUSC GRP EACH 20553 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 32301053 RADIOLOGY - IR INJ TX PSEUDOANEUR EXTREM PERC EACH 36002 "$1,554.00 " 510 "$1,087.80 " $777.00 "$1,243.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32302143 RADIOLOGY - IR INJ URETEROGRAPHY EACH 50684 $730.00 510 $511.00 $365.00 $584.00 65% 80% 50% 50% 65% Non Payable Non Payable 32306003 RADIOLOGY - IR INJ VENOGRAM EXTREMITY EACH 36005 $510.00 510 $357.00 $255.00 $408.00 65% 80% 50% 50% 65% Non Payable Non Payable 32307001 RADIOLOGY - IR INJECT FOR LYMPHATIC X-RAY EACH 38790 $570.00 510 $399.00 $285.00 $456.00 65% 80% 50% 50% 65% Non Payable Non Payable 32309494 RADIOLOGY - IR INJECT FOR SACROILIAC JOINT EACH G0259 $432.00 320 $302.40 $216.00 $345.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $45.89 65% of Billed Charges 65% of Billed Charges 32307787 RADIOLOGY - IR INJECTION INTO BRAIN CANAL EACH 61055 $733.00 510 $513.10 $366.50 $586.40 65% 80% 50% 50% 65% Non Payable Non Payable 32305153 RADIOLOGY - IR INJECTION OF SINUS TRACT EACH 20500 "$3,771.00 " 510 "$2,639.70 " "$1,885.50 " "$3,016.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301301 RADIOLOGY - IR INS CATH CV NON-TUNL >5YRS EACH 36556 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301327 RADIOLOGY - IR INS CATH CV TUNLW/O PORT >5YRS EACH 36558 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301319 RADIOLOGY - IR INS CATH CV TUNLW/O PORT<5YRS EACH 36557 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301384 RADIOLOGY - IR INS CATH PERIPH CV W/O PORT <5 EACH 36568 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301400 RADIOLOGY - IR INS CATH PERIPH CV W/PORT <5 EACH 36570 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301418 RADIOLOGY - IR INS CATH PERIPH CV W/PORT >5 EACH 36571 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306334 RADIOLOGY - IR INS CATH REN ART 1ST BILAT EACH 36252 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304537 RADIOLOGY - IR INS CATH REN ART 1ST UNILAT EACH 36251 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $287.90 65% of Billed Charges 65% of Billed Charges 32306359 RADIOLOGY - IR INS CATH REN ART 2ND+ BILAT EACH 36254 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306342 RADIOLOGY - IR INS CATH REN ART 2ND+ UNI EACH 36253 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301368 RADIOLOGY - IR INS DEVICE CV 2 CATH W/O P/P EACH 36565 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301376 RADIOLOGY - IR INS DEVICE CV 2 CATH W/PORT EACH 36566 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301335 RADIOLOGY - IR INS DEVICE CV W/PORT < 5 YRS EACH 36560 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301343 RADIOLOGY - IR INS DEVICE CV W/PORT > 5 YRS EACH 36561 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301392 RADIOLOGY - IR INS PER CV CATH W/O PORT 5> EACH 36569 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301350 RADIOLOGY - IR INS PUMP IV INFUSION EACH 36563 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307423 RADIOLOGY - IR INS TUN IP CATH DIAL OPN EACH 49421 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306490 RADIOLOGY - IR INSER CATHETER VEIN VENOUS EACH 36500 $213.00 510 $149.10 $106.50 $170.40 65% 80% 50% 50% 65% Non Payable Non Payable 32307449 RADIOLOGY - IR INSERT ABDOMEN-VENOUS DRAIN EACH 49425 "$2,210.00 " 510 "$1,547.00 " "$1,105.00 " "$1,768.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32300378 RADIOLOGY - IR INSERT CATH PLEURAL INDWELL W/ EACH 32550 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306482 RADIOLOGY - IR INSERT CATHETER VEIN PERC EACH 36481 $213.00 510 $149.10 $106.50 $170.40 65% 80% 50% 50% 65% Non Payable Non Payable 32305765 RADIOLOGY - IR INSERT ENDOVASC PROSTH TAA EACH 33883 "$9,024.00 " 510 "$6,316.80 " "$4,512.00 " "$7,219.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306607 RADIOLOGY - IR INSERT HEPATIC SHUNT (TIPS) EACH 37182 "$11,586.00 " 510 "$8,110.20 " "$5,793.00 " "$9,268.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307472 RADIOLOGY - IR INSERT SUBQ EXTEN IP CATH EACH 49435 $355.00 510 $248.50 $177.50 $284.00 65% 80% 50% 50% 65% Non Payable Non Payable 32307415 RADIOLOGY - IR INSERT TUN IP CATH PERC EACH 49418 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306540 RADIOLOGY - IR INSERTION OF CANNULA EACH 36800 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309379 RADIOLOGY - IR INSERTION SWAN GANZ EACH 93503 "$3,960.00 " 480 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% of Billed Charges 80% of Billed Charges $352/visit $320/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 32307852 RADIOLOGY - IR INTERDISCAL PERQ ASPIR DX EACH 62267 "$1,740.00 " 510 "$1,218.00 " $870.00 "$1,392.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307811 RADIOLOGY - IR INTRACRAN ANGIOPLST W/STENT EACH 61635 "$4,038.00 " 510 "$2,826.60 " "$2,019.00 " "$3,230.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307803 RADIOLOGY - IR INTRACRANIAL ANGIOPLASTY EACH 61630 "$3,738.00 " 510 "$2,616.60 " "$1,869.00 " "$2,990.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301178 RADIOLOGY - IR INTRO CATH AORTA EACH 36200 $708.00 510 $495.60 $354.00 $566.40 65% 80% 50% 50% 65% Non Payable Non Payable 32301103 RADIOLOGY - IR INTRO CATH ARTERY HEART/PULM EACH 36013 $286.00 510 $200.20 $143.00 $228.80 65% 80% 50% 50% 65% Non Payable Non Payable 32304834 RADIOLOGY - IR INTRO CATH DIALYSIS CIRCUIT EACH 36901 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304842 RADIOLOGY - IR INTRO CATH DIALYSIS W/ANGIO EACH 36902 "$14,132.00 " 510 "$9,892.40 " "$7,066.00 " "$11,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304859 RADIOLOGY - IR INTRO CATH DIALYSIS W/STENT EACH 36903 "$27,201.00 " 510 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301079 RADIOLOGY - IR INTRO CATH VENA CAVA SUP/INF EACH 36010 $510.00 510 $357.00 $255.00 $408.00 65% 80% 50% 50% 65% Non Payable Non Payable 32307092 RADIOLOGY - IR INTRO GASTROINTESTINAL TUBE EACH 44500 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301152 RADIOLOGY - IR INTRO NDL/CATH ARTERY EXTREM EACH 36140 $627.00 510 $438.90 $313.50 $501.60 65% 80% 50% 50% 65% Non Payable Non Payable 32306938 RADIOLOGY - IR LIGATION OF A-V FISTULA EACH 37607 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32302507 RADIOLOGY - IR LUMBAR PUNCTURE DIAGNOSTIC EACH 62270 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32302515 RADIOLOGY - IR LUMBAR PUNCTURE DRAIN CSF EACH 62272 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32308975 RADIOLOGY - IR LYMPH VESSEL X-RAY TRUNK BI EACH 75807 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges $302.04 $302.04 "$2,577.95 " 65% of Billed Charges 65% of Billed Charges 32308967 RADIOLOGY - IR LYMPH VESSEL X-RAY TRUNK UNI EACH 75805 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges $302.04 $302.04 "$1,521.44 " 65% of Billed Charges 65% of Billed Charges 32305716 RADIOLOGY - IR LYSE CHEST FIBRIN INIT DAY EACH 32561 "$1,554.00 " 510 "$1,087.80 " $777.00 "$1,243.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305724 RADIOLOGY - IR LYSE CHEST FIBRIN SUBQ DAY EACH 32562 "$1,554.00 " 510 "$1,087.80 " $777.00 "$1,243.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305120 RADIOLOGY - IR MAMM DUCTOGRAM INJ EACH 19030 $176.00 510 $123.20 $88.00 $140.80 65% 80% 50% 50% 65% Non Payable Non Payable 32309353 RADIOLOGY - IR MRI FOR TISSUE ABLATION EACH 77022 "$3,601.00 " 610 "$2,520.70 " "$1,800.50 " "$2,880.80 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 32309346 RADIOLOGY - IR MRI GUIDE NDL PLACE EACH 77021 "$3,601.00 " 610 "$2,520.70 " "$1,800.50 " "$2,880.80 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 32307951 RADIOLOGY - IR MYELOGRAPHY LUMBAR 2+ REGIONS EACH 62305 "$1,980.00 " 320 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $122.78 65% of Billed Charges 65% of Billed Charges 32307928 RADIOLOGY - IR MYELOGRAPHY LUMBAR CERVICAL EACH 62302 "$1,980.00 " 320 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $119.84 65% of Billed Charges 65% of Billed Charges 32307936 RADIOLOGY - IR MYELOGRAPHY LUMBAR INJECTION EACH 62303 "$1,980.00 " 320 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $119.84 65% of Billed Charges 65% of Billed Charges 32307944 RADIOLOGY - IR MYELOGRAPHY LUMBAR LUMBOSACRAL EACH 62304 "$1,980.00 " 320 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $118.21 65% of Billed Charges 65% of Billed Charges 32307076 RADIOLOGY - IR NASAL/OROGASTRIC W/STENT EACH 43752 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 32302184 RADIOLOGY - IR NJ CYSTOGRAM EACH 51600 $168.00 510 $117.60 $84.00 $134.40 65% 80% 50% 50% 65% Non Payable Non Payable 32302192 RADIOLOGY - IR NJ URETHROCYSTOGRAM RETRO EACH 51610 $323.00 510 $226.10 $161.50 $258.40 65% 80% 50% 50% 65% Non Payable Non Payable 32304594 RADIOLOGY - IR "NS CATH PLACE, TH AORTA, W/ANG" EACH 36221 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $227.80 65% of Billed Charges 65% of Billed Charges 32302481 RADIOLOGY - IR OCC/EMB TRANSCATH CNS PERC EACH 61624 "$16,402.00 " 360 "$11,481.40 " "$8,201.00 " "$13,121.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " "$1,235.62 " "$1,266 " "$1,266 " 32302499 RADIOLOGY - IR OCC/EMB TRANSCATH NON-CNS PERC EACH 61626 "$27,201.00 " 510 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305823 RADIOLOGY - IR OPEN AORTOILIAC PROSTH REPR EACH 34831 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305625 RADIOLOGY - IR OPEN BIOPSY OF LUNG PLEURA EACH 32098 "$1,910.00 " 510 "$1,337.00 " $955.00 "$1,528.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307100 RADIOLOGY - IR OPEN DRAINAGE LIVER LESION EACH 47010 "$10,381.00 " 510 "$7,266.70 " "$5,190.50 " "$8,304.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306557 RADIOLOGY - IR OPEN THROMBECT AV FISTULA EACH 36831 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306813 RADIOLOGY - IR OPEN/PERQ PLACE STENT 1ST EACH 37236 "$27,201.00 " 510 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306839 RADIOLOGY - IR OPEN/PERQ PLACE STENT ADD EACH 37237 "$6,027.00 " 510 "$4,218.90 " "$3,013.50 " "$4,821.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306870 RADIOLOGY - IR OPEN/PERQ PLACE STENT ADDL EACH 37239 "$6,027.00 " 510 "$4,218.90 " "$3,013.50 " "$4,821.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306854 RADIOLOGY - IR OPEN/PERQ PLACE STENT SAME EACH 37238 "$27,201.00 " 510 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309700 RADIOLOGY - IR PERC NEPH CATH EACH 50432 "$5,037.00 " 320 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $213.90 65% of Billed Charges 65% of Billed Charges 32309742 RADIOLOGY - IR PERC URETER STENT EXISTING EACH 50693 "$8,620.00 " 320 "$6,034.00 " "$4,310.00 " "$6,896.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $212.26 65% of Billed Charges 65% of Billed Charges 32309767 RADIOLOGY - IR PERC URETER STENT NEW ACCSS EACH 50694 "$8,620.00 " 320 "$6,034.00 " "$4,310.00 " "$6,896.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $279.28 65% of Billed Charges 65% of Billed Charges 32307118 RADIOLOGY - IR PERCUT ABLATE LIVER RF EACH 47382 "$14,267.00 " 510 "$9,986.90 " "$7,133.50 " "$11,413.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307340 RADIOLOGY - IR PERITONEAL LAVAGE W/IMAGING EACH 49084 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307126 RADIOLOGY - IR PERQ ABLTJ LVR CRYOABLATION EACH 47383 "$25,452.00 " 510 "$17,816.40 " "$12,726.00 " "$20,361.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309536 RADIOLOGY - IR PERQ ART M-THROMBECT &/NFS EACH 61645 "$1,629.00 " 510 "$1,140.30 " $814.50 "$1,303.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304735 RADIOLOGY - IR PERQ CERVICOTHORACIC INJ EACH 22510 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305039 RADIOLOGY - IR PERQ LAMOT/LAM LUMBAR EACH 0275T "$17,689.00 " 320 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $394.70 65% of Billed Charges 65% of Billed Charges 32304743 RADIOLOGY - IR PERQ LUMBOSACRAL INJ EACH 22511 "$8,004.00 " 510 "$5,602.80 " "$4,002.00 " "$6,403.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305021 RADIOLOGY - IR PERQ SACRAL AUGMT BILAT INJ EACH 0201T "$17,689.00 " 361 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,267 " "$1,152 " "$2,656.28 " "$2,526 " "$2,526 " 32305013 RADIOLOGY - IR PERQ SACRAL AUGMT UNILAT INJ EACH 0200T "$17,689.00 " 361 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,267 " "$1,152 " "$1,818.09 " "$2,426 " "$2,426 " 32304776 RADIOLOGY - IR PERQ VERTEBRAL AUG LUMBAR EACH 22514 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304768 RADIOLOGY - IR PERQ VERTEBRAL AUG THORACIC EACH 22513 "$17,689.00 " 510 "$12,382.30 " "$8,844.50 " "$14,151.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304784 RADIOLOGY - IR PERQ VERTEBRAL AUGMENT EA ADDL EACH 22515 "$3,952.00 " 510 "$2,766.40 " "$1,976.00 " "$3,161.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307688 RADIOLOGY - IR PF-CH EXT/INT URETER STENT EACH 50387 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307761 RADIOLOGY - IR PF-EXPLORE ADRENAL GLAND EACH 60540 "$3,046.00 " 510 "$2,132.20 " "$1,523.00 " "$2,436.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32308561 RADIOLOGY - IR PF-INJ FOR TEAR SAC X-RAY EACH 68850 $152.00 510 $106.40 $76.00 $121.60 65% 80% 50% 50% 65% Non Payable Non Payable 32307746 RADIOLOGY - IR PF-INSTLL RX AGNT RNL TUB EACH 50391 $612.00 510 $428.40 $306.00 $489.60 65% 80% 50% 50% 65% Non Payable Non Payable 32307704 RADIOLOGY - IR PF-REM RENAL TUBE W/FLUORO EACH 50389 "$1,689.00 " 510 "$1,182.30 " $844.50 "$1,351.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307662 RADIOLOGY - IR PF-REM STENT VIA TRANSURETH EACH 50386 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307647 RADIOLOGY - IR PF-REMOVE URETER STENT PERC EACH 50384 "$5,037.00 " 510 "$3,525.90 " "$2,518.50 " "$4,029.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306979 RADIOLOGY - IR PHLEB VEINS - EXTREM 20+ EACH 37766 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309486 RADIOLOGY - IR PHLEBOTOMY THERAPEUTIC EACH 99195 $316.00 940 $221.20 $158.00 $252.80 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 32300014 RADIOLOGY - IR PL STNT T/C X-VERT/IN-CAROT IN EACH 0075T "$10,459.00 " 320 "$7,321.30 " "$5,229.50 " "$8,367.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable "$2,141.37 " 65% of Billed Charges 65% of Billed Charges 32301228 RADIOLOGY - IR PLACE CATH ABD/PEL 1ST ORDER EACH 36245 $510.00 510 $357.00 $255.00 $408.00 65% 80% 50% 50% 65% Non Payable Non Payable 32301236 RADIOLOGY - IR PLACE CATH ABD/PEL 2ND ORDER EACH 36246 "$1,082.00 " 510 $757.40 $541.00 $865.60 65% 80% 50% 50% 65% Non Payable Non Payable 32301244 RADIOLOGY - IR PLACE CATH ABD/PEL 3RD ORDER EACH 36247 $510.00 510 $357.00 $255.00 $408.00 65% 80% 50% 50% 65% Non Payable Non Payable 32301251 RADIOLOGY - IR PLACE CATH ABD/PEL ADD EACH 36248 $380.00 510 $266.00 $190.00 $304.00 65% 80% 50% 50% 65% Non Payable Non Payable 32306086 RADIOLOGY - IR PLACE CATH ARTERY PULM L/R EACH 36014 $510.00 510 $357.00 $255.00 $408.00 65% 80% 50% 50% 65% Non Payable Non Payable 32306102 RADIOLOGY - IR PLACE CATH ARTERY PULM SEG EACH 36015 $510.00 510 $357.00 $255.00 $408.00 65% 80% 50% 50% 65% Non Payable Non Payable 32301186 RADIOLOGY - IR PLACE CATH THOR/BRAC 1ST ORDER EACH 36215 $868.00 510 $607.60 $434.00 $694.40 65% 80% 50% 50% 65% Non Payable Non Payable 32301194 RADIOLOGY - IR PLACE CATH THOR/BRAC 2ND ORDER EACH 36216 $822.00 510 $575.40 $411.00 $657.60 65% 80% 50% 50% 65% Non Payable Non Payable 32301202 RADIOLOGY - IR PLACE CATH THOR/BRAC 3RD ORDER EACH 36217 $822.00 510 $575.40 $411.00 $657.60 65% 80% 50% 50% 65% Non Payable Non Payable 32301210 RADIOLOGY - IR PLACE CATH THOR/BRAC ADD EACH 36218 $513.00 510 $359.10 $256.50 $410.40 65% 80% 50% 50% 65% Non Payable Non Payable 32306045 RADIOLOGY - IR PLACE CATH VENOUS 1ST ORDER EACH 36011 $510.00 510 $357.00 $255.00 $408.00 65% 80% 50% 50% 65% Non Payable Non Payable 32307498 RADIOLOGY - IR PLACE DUOD/JEJ TUBE PERC EACH 49441 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307480 RADIOLOGY - IR PLACE GASTROSTOMY TUBE PERC EACH 49440 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32303950 RADIOLOGY - IR PLACE OCCLUSIVE DEVICE A/V EACH G0269 $268.00 320 $187.60 $134.00 $214.40 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $175.27 65% of Billed Charges 65% of Billed Charges 32305138 RADIOLOGY - IR PLACE PO BREAST CATH RAD EACH 19296 "$23,308.00 " 510 "$16,315.60 " "$11,654.00 " "$18,646.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307308 RADIOLOGY - IR PLACEMENT BILE DUCT SUPPORT EACH 47801 "$2,883.00 " 510 "$2,018.10 " "$1,441.50 " "$2,306.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304578 RADIOLOGY - IR PLEURAL DRAIN W/INSERT CATH W EACH 32557 "$3,960.00 " 320 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $168.28 65% of Billed Charges 65% of Billed Charges 32304560 RADIOLOGY - IR PLEURAL DRAIN W/INSERT CATH WO EACH 32556 "$4,705.00 " 510 "$3,293.50 " "$2,352.50 " "$3,764.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307233 RADIOLOGY - IR PLMT ACCESS BIL TREE SM BWL EACH 47541 "$18,706.00 " 510 "$13,094.20 " "$9,353.00 " "$14,964.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307209 RADIOLOGY - IR PLMT BILE DUCT STENT EX ACCESS EACH 47538 "$14,267.00 " 510 "$9,986.90 " "$7,133.50 " "$11,413.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307225 RADIOLOGY - IR PLMT BILE DUCT STENT EXT/INT EACH 47540 "$14,267.00 " 510 "$9,986.90 " "$7,133.50 " "$11,413.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307217 RADIOLOGY - IR PLMT BILE DUCT STENT NEW ACCSS EACH 47539 "$14,267.00 " 510 "$9,986.90 " "$7,133.50 " "$11,413.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307167 RADIOLOGY - IR PLMT BILIARY DRAIN CTH INT/EXT EACH 47534 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307159 RADIOLOGY - IR PLMT BILIARY DRAINAGE CATH EXT EACH 47533 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306623 RADIOLOGY - IR PRIM ART MECH THROMBECTOMY EACH 37184 "$43,356.00 " 510 "$30,349.20 " "$21,678.00 " "$34,684.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306631 RADIOLOGY - IR PRIM ART M-THROMBECT ADD-ON EACH 37185 "$2,454.00 " 510 "$1,717.80 " "$1,227.00 " "$1,963.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309411 RADIOLOGY - IR PUMP MAINT SPNL/BRAIN ADM DR EACH 95991 $733.00 335 $513.10 $366.50 $586.40 65% of Billed Charges 80% of Billed Charges $407/visit $325/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 32302473 RADIOLOGY - IR PUNCT ASP/INJ SHUNT TUBE EACH 61070 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305088 RADIOLOGY - IR PUNCTURE DRAINAGE OF LESION EACH 10160 $986.00 510 $690.20 $493.00 $788.80 65% 80% 50% 50% 65% Non Payable Non Payable 32308207 RADIOLOGY - IR PVB THORACIC 2ND+ INJ SITE EACH 64462 $377.00 510 $263.90 $188.50 $301.60 65% 80% 50% 50% 65% Non Payable Non Payable 32308215 RADIOLOGY - IR PVB THORACIC CONT INFUSION EACH 64463 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32308199 RADIOLOGY - IR PVB THORACIC SINGLE INJ SITE EACH 64461 "$1,710.00 " 510 "$1,197.00 " $855.00 "$1,368.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306680 RADIOLOGY - IR REDO ENDOV VENA CAVA FILTR EACH 37192 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301558 RADIOLOGY - IR REM INTRALUM MAT CV LUMEN EACH 36596 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301541 RADIOLOGY - IR REM PERICATHETER MAT CV DEV EACH 36595 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301533 RADIOLOGY - IR REM TNL CV ACC W/PORT/PUMP EACH 36590 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301517 RADIOLOGY - IR REM TNLD CV CATH W/O PORT/PUMP EACH 36589 "$1,554.00 " 510 "$1,087.80 " $777.00 "$1,243.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307191 RADIOLOGY - IR REMOVAL BILIARY DRG CATH EACH 47537 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307266 RADIOLOGY - IR REMOVAL DUCT GLBLDR CALCULI EACH 47544 $450.00 510 $315.00 $225.00 $360.00 65% 80% 50% 50% 65% Non Payable Non Payable 32305997 RADIOLOGY - IR REMOVAL OF CLOT IN GRAFT EACH 35875 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306367 RADIOLOGY - IR REMOVAL OF INFUSION PUMP EACH 36262 "$9,710.00 " 510 "$6,797.00 " "$4,855.00 " "$7,768.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307464 RADIOLOGY - IR REMOVAL OF SHUNT EACH 49429 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309080 RADIOLOGY - IR REMOVE CVA DEVICE OBSTRUCT EACH 75901 $66.00 320 $46.20 $33.00 $52.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $206.15 65% of Billed Charges 65% of Billed Charges 32309114 RADIOLOGY - IR REMOVE CVA LUMEN OBSTRUCT EACH 75902 $70.00 320 $49.00 $35.00 $56.00 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $80.82 65% of Billed Charges 65% of Billed Charges 32306615 RADIOLOGY - IR REMOVE HEPATIC SHUNT (TIPS) EACH 37183 "$14,132.00 " 510 "$9,892.40 " "$7,066.00 " "$11,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307563 RADIOLOGY - IR REMOVE KIDNEY STONE <2M EACH 50080 "$22,778.00 " 510 "$15,944.60 " "$11,389.00 " "$18,222.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307589 RADIOLOGY - IR REMOVE KIDNEY STONE >2M EACH 50081 "$22,778.00 " 510 "$15,944.60 " "$11,389.00 " "$18,222.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305658 RADIOLOGY - IR REMOVE LUNG CATHETER EACH 32552 "$1,554.00 " 510 "$1,087.80 " $777.00 "$1,243.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305419 RADIOLOGY - IR REMOVE SHOULDER FOREIGN BDY EACH 23330 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307431 RADIOLOGY - IR REMOVE TUNNELED IP CATH EACH 49422 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304727 RADIOLOGY - IR REMOVE VENA CAVA FILTER EACH 37193 "$7,882.00 " 361 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,267 " "$1,152 " $381.53 "$1,266 " "$1,266 " 32301459 RADIOLOGY - IR REPL CATH CV NON-TNL W/O PORT EACH 36580 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301467 RADIOLOGY - IR REPL CATH CV TNL W/O PORT EACH 36581 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301442 RADIOLOGY - IR REPL CATH CV W/PORT/PUMP EACH 36578 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301475 RADIOLOGY - IR REPL DEVICE CV TNL W/PORT EACH 36582 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301483 RADIOLOGY - IR REPL DEVICE CV TNL W/PUMP EACH 36583 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301491 RADIOLOGY - IR REPL PICC W/O PORT/PUMP EACH 36584 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301509 RADIOLOGY - IR REPL PICC W/PORT EACH 36585 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307522 RADIOLOGY - IR REPLACE DUOD/JEJ TUBE PERC EACH 49451 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307514 RADIOLOGY - IR REPLACE G/C TUBE PERC EACH 49450 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307530 RADIOLOGY - IR REPLACE G-J TUBE PERC EACH 49452 "$2,242.00 " 510 "$1,569.40 " "$1,121.00 " "$1,793.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307084 RADIOLOGY - IR REPOSITION GASTROSTOMY TUBE EACH 43761 $612.00 510 $428.40 $306.00 $489.60 65% 80% 50% 50% 65% Non Payable Non Payable 32306524 RADIOLOGY - IR REPOSITION VENOUS CATHETER EACH 36597 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32307456 RADIOLOGY - IR REVISE ABDOMEN-VENOUS SHUNT EACH 49426 "$8,555.00 " 510 "$5,988.50 " "$4,277.50 " "$6,844.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306946 RADIOLOGY - IR REVISION OF MAJOR VEIN EACH 37660 "$5,722.00 " 510 "$4,005.40 " "$2,861.00 " "$4,577.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301426 RADIOLOGY - IR RPR CATH CV W/O PORT/PUMP EACH 36575 "$1,554.00 " 510 "$1,087.80 " $777.00 "$1,243.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32301434 RADIOLOGY - IR RPR CATH CV W/PORT/PUMP EACH 36576 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305005 RADIOLOGY - IR S&I STENT/CHEST VERT ART EACH 0076T $110.00 320 $77.00 $55.00 $88.00 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable "$1,702.23 " 65% of Billed Charges 65% of Billed Charges 32307365 RADIOLOGY - IR SCLEROTX FLUID COLLECTION EACH 49185 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306649 RADIOLOGY - IR SEC ART M-THROMBECT ADD-ON EACH 37186 "$1,430.50 " 510 "$1,001.35 " $715.25 "$1,144.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304651 RADIOLOGY - IR SEL CATH PLACE CA UNI W/ANGIO EACH 36227 $323.00 323 $226.10 $161.50 $258.40 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $134.34 65% of Billed Charges 65% of Billed Charges 32306185 RADIOLOGY - IR SEL CATH PLACE ICC UNI W/A EACH 36224 "$13,588.00 " 323 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $411.35 65% of Billed Charges 65% of Billed Charges 32304636 RADIOLOGY - IR SEL CATH PLACE SC/IA UNI W/ANG EACH 36225 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $359.20 65% of Billed Charges 65% of Billed Charges 32313090 RADIOLOGY - IR "SEL CATH PLACE TH AORTA,W/A" EACH 36222 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $320.48 65% of Billed Charges 65% of Billed Charges 32306227 RADIOLOGY - IR SEL CATH PLACE VA UNI W/A EACH 36226 "$13,588.00 " 323 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $403.94 65% of Billed Charges 65% of Billed Charges 32306169 RADIOLOGY - IR SEL CTH PLACE CC/IA UNI W/A EACH 36223 "$13,588.00 " 323 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $359.38 65% of Billed Charges 65% of Billed Charges 32306250 RADIOLOGY - IR SEL CTH PLACE IB EA UNI W/A EACH 36228 $323.00 323 $226.10 $161.50 $258.40 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $275.78 65% of Billed Charges 65% of Billed Charges 32306961 RADIOLOGY - IR STAB PHLEB VEINS XTR 10-20 EACH 37765 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306722 RADIOLOGY - IR STENT PLACEMT ANTE CAROTID EACH 37218 "$1,304.00 " 360 $912.80 $652.00 "$1,043.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case $319 $290 $926.05 "$1,266 " "$1,266 " 32309957 RADIOLOGY - IR STENT PLMT CTR DIALYSIS SEG EACH 36908 "$3,015.00 " 323 "$2,110.50 " "$1,507.50 " "$2,412.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $228.63 65% of Billed Charges 65% of Billed Charges 32309403 RADIOLOGY - IR TENSILON TEST EACH 95857 $777.00 920 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 32304552 RADIOLOGY - IR THORACENTESIS-PLEURAL W/GUIDE EACH 32555 "$1,554.00 " 320 "$1,087.80 " $777.00 "$1,243.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $122.93 65% of Billed Charges 65% of Billed Charges 32304545 RADIOLOGY - IR THORACENTESIS-PLEURAL WO GUIDE EACH 32554 "$1,554.00 " 510 "$1,087.80 " $777.00 "$1,243.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304586 RADIOLOGY - IR THORACIC TARGET(S)(SRS/SBRT) EACH 32701 $250.00 333 $175.00 $125.00 $200.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 32300386 RADIOLOGY - IR THORACOSTOMY INS CHEST TUBE EACH 32551 "$3,960.00 " 510 "$2,772.00 " "$1,980.00 " "$3,168.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306698 RADIOLOGY - IR THROMBOLYTIC THERAPY STROKE EACH 37195 $838.00 510 $586.60 $419.00 $670.40 65% 80% 50% 50% 65% Non Payable Non Payable 32306797 RADIOLOGY - IR TIB/PER REVASC ADD VSL W/AT EACH 37233 $360.00 360 $252.00 $180.00 $288.00 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $369.59 Non Payable Non Payable 32306771 RADIOLOGY - IR TIB/PER REVASC ADD VSL W/TL EACH 37232 $360.00 360 $252.00 $180.00 $288.00 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,672 " "$1,520 " $226.83 Non Payable Non Payable 32304461 RADIOLOGY - IR TIB/PER REVASC EA ADD VESL W/S EACH 37234 "$9,450.00 " 360 "$6,615.00 " "$4,725.00 " "$7,560.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,672 " "$1,520 " $324.76 Non Payable Non Payable 32304412 RADIOLOGY - IR TIB/PER REVASC W/ATHERECT EACH 37229 "$43,356.00 " 360 "$30,349.20 " "$21,678.00 " "$34,684.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $797.92 "$1,266 " "$1,266 " 32304420 RADIOLOGY - IR TIB/PER REVASC W/STENT EACH 37230 "$43,356.00 " 360 "$30,349.20 " "$21,678.00 " "$34,684.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $795.38 "$1,266 " "$1,266 " 32304438 RADIOLOGY - IR TIB/PER REVASC W/STENT&ATHER EACH 37231 "$43,356.00 " 360 "$30,349.20 " "$21,678.00 " "$34,684.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$2,695 " "$2,450 " $859.47 "$1,266 " "$1,266 " 32304404 RADIOLOGY - IR TIB/PER REVASC W/TLA EACH 37228 "$27,201.00 " 360 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,672 " "$1,520 " $618.27 "$1,266 " "$1,266 " 32304479 RADIOLOGY - IR TIB/PER RVSC EA ADD VSL W/STNT EACH 37235 "$9,450.00 " 360 "$6,615.00 " "$4,725.00 " "$7,560.00 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,672 " "$1,520 " $456.17 Non Payable Non Payable 32304677 RADIOLOGY - IR TRANCATHETER RETRIEVAL PERC FB EACH 37197 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306706 RADIOLOGY - IR TRANSCATH STENT CCA W/EPS EACH 37215 $360.00 510 $252.00 $180.00 $288.00 65% 80% 50% 50% 65% Non Payable Non Payable 32306714 RADIOLOGY - IR TRANSCATH STENT CCA W/O EPS EACH 37216 $360.00 360 $252.00 $180.00 $288.00 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case $319 $290 "$1,030.37 " "$1,266 " "$1,266 " 32304719 RADIOLOGY - IR "TRANSCATH THERAPY, SUBSEQ CESS" EACH 37214 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304701 RADIOLOGY - IR "TRANSCATH THERAPY, SUBSEQ DAY " EACH 37213 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304693 RADIOLOGY - IR "TRANSCATH THERAPY, VENOUS INF " EACH 37212 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304685 RADIOLOGY - IR "TRANSCATH THERAPY,ARTERIAL INF" EACH 37211 "$13,588.00 " 510 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305708 RADIOLOGY - IR TREAT PLEURODESIS W/AGENT EACH 32560 "$1,554.00 " 510 "$1,087.80 " $777.00 "$1,243.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304958 RADIOLOGY - IR TRLML BALO ANGIOP ADDL VEIN EACH 37249 "$3,015.00 " 510 "$2,110.50 " "$1,507.50 " "$2,412.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304891 RADIOLOGY - IR TRLUML BALO ANGIOP 1ST ART EACH 37246 "$14,132.00 " 510 "$9,892.40 " "$7,066.00 " "$11,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304933 RADIOLOGY - IR TRLUML BALO ANGIOP 1ST VEIN EACH 37248 "$14,132.00 " 510 "$9,892.40 " "$7,066.00 " "$11,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304917 RADIOLOGY - IR TRLUML BALO ANGIOP ADDL ART EACH 37247 "$3,015.00 " 510 "$2,110.50 " "$1,507.50 " "$2,412.00 " 65% 80% 50% 50% 65% Non Payable Non Payable 32304313 RADIOLOGY - IR TRLUML PERIP ATHEREC ABD AORTA EACH 0236T "$27,201.00 " 361 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " "$1,326.48 " "$1,266 " "$1,266 " 32304321 RADIOLOGY - IR TRLUML PERIP ATHEREC BRACHIOCP EACH 0237T "$27,201.00 " 361 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $731.40 "$1,266 " "$1,266 " 32304495 RADIOLOGY - IR TRLUML PERIP ATHEREC ILIAC ART EACH 0238T "$43,356.00 " 361 "$30,349.20 " "$21,678.00 " "$34,684.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $915.08 "$1,266 " "$1,266 " 32304487 RADIOLOGY - IR TRLUML PERIP ATHEREC RENAL ART EACH 0234T "$27,201.00 " 361 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " "$1,562.27 " "$1,266 " "$1,266 " 32304305 RADIOLOGY - IR TRLUML PERIP ATHEREC VISCERAL EACH 0235T "$15,966.35 " 360 "$11,176.45 " "$7,983.18 " "$12,773.08 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case $319 $290 "$1,561.53 " "$1,266 " "$1,266 " 32309809 RADIOLOGY - IR URETER EMBOLIZATION EACH 50705 "$2,805.00 " 320 "$1,963.50 " "$1,402.50 " "$2,244.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $185.67 65% of Billed Charges 65% of Billed Charges 32309783 RADIOLOGY - IR URETER STENT NEW W/NEPH CTH EACH 50695 "$8,620.00 " 320 "$6,034.00 " "$4,310.00 " "$6,896.00 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $357.55 65% of Billed Charges 65% of Billed Charges 32309189 RADIOLOGY - IR US ABDOMEN LIMITED EACH 76705 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $86.30 Non Payable Non Payable 32309221 RADIOLOGY - IR US GUIDE TISSUE ABLATION EACH 76940 $289.00 402 $202.30 $144.50 $231.20 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $164.75 Non Payable Non Payable 32309205 RADIOLOGY - IR US GUIDE VASCULAR ACCESS EACH 76937 $43.00 402 $30.10 $21.50 $34.40 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $34.64 Non Payable Non Payable 32309247 RADIOLOGY - IR US GUIDED NEEDLE PLACEMENT S&I EACH 76942 $514.00 402 $359.80 $257.00 $411.20 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $54.52 Non Payable Non Payable 32312613 RADIOLOGY - IR VASC EMBOLIZE/OCCLUDE ART EACH 37242 "$43,356.00 " 360 "$30,349.20 " "$21,678.00 " "$34,684.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $523.34 "$1,266 " "$1,266 " 32312654 RADIOLOGY - IR VASC EMBOLIZE/OCCLUDE BLEED EACH 37244 "$27,201.00 " 360 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $710.18 "$1,266 " "$1,266 " 32312639 RADIOLOGY - IR VASC EMBOLIZE/OCCLUDE ORGAN EACH 37243 "$27,201.00 " 360 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $599.20 "$1,266 " "$1,266 " 32312597 RADIOLOGY - IR VASC EMBOLIZE/OCCLUDE VEN EACH 37241 "$27,201.00 " 360 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case "$1,958 " "$1,780 " $482.87 "$1,266 " "$1,266 " 32309031 RADIOLOGY - IR VEIN X-RAY EYE SOCKET EACH 75880 "$1,554.00 " 320 "$1,087.80 " $777.00 "$1,243.20 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $111.89 65% of Billed Charges 65% of Billed Charges 32309049 RADIOLOGY - IR VEIN X-RAY LIVER W/HEMODYNAM EACH 75885 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $141.87 65% of Billed Charges 65% of Billed Charges 32309056 RADIOLOGY - IR VEIN X-RAY LIVER W/O HEMODYN EACH 75887 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $142.87 65% of Billed Charges 65% of Billed Charges 32309007 RADIOLOGY - IR VEIN X-RAY NECK EACH 75860 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $131.48 65% of Billed Charges 65% of Billed Charges 32309015 RADIOLOGY - IR VEIN X-RAY SKULL EACH 75870 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $177.78 65% of Billed Charges 65% of Billed Charges 32309023 RADIOLOGY - IR VEIN X-RAY SKULL EPIDURAL EACH 75872 "$1,554.00 " 320 "$1,087.80 " $777.00 "$1,243.20 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $133.05 65% of Billed Charges 65% of Billed Charges 32308983 RADIOLOGY - IR VEIN X-RAY SPLEEN/LIVER EACH 75810 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " "$1,519.59 " 65% of Billed Charges 65% of Billed Charges 32306375 RADIOLOGY - IR VENIPUNCTURE EACH 36415 $8.00 300 $5.60 $4.00 $6.40 65% 80% 50% 50% 65% 65% 65% 32308991 RADIOLOGY - IR VENOGRAPHY RENAL BILAT EXAM EACH 75833 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $152.59 65% of Billed Charges 65% of Billed Charges 32306656 RADIOLOGY - IR VENOUS MECH THROMBECTOMY EACH 37187 "$27,201.00 " 510 "$19,040.70 " "$13,600.50 " "$21,760.80 " 65% 80% 50% 50% 65% Non Payable Non Payable 32306664 RADIOLOGY - IR VENOUS M-THROMBECTMY ADD-ON EACH 37188 "$7,882.00 " 510 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32309064 RADIOLOGY - IR VENOUS SAMPLING BY CATHETER EACH 75893 "$13,588.00 " 320 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $109.60 65% of Billed Charges 65% of Billed Charges 32304750 RADIOLOGY - IR VERTEBROPLASTY ADDL INJECT EACH 22512 "$1,627.00 " 510 "$1,138.90 " $813.50 "$1,301.60 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305872 RADIOLOGY - IR VISC & INFRAREN ABD 1 PROSTH EACH 34845 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305880 RADIOLOGY - IR VISC & INFRAREN ABD 2 PROSTH EACH 34846 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305898 RADIOLOGY - IR VISC & INFRAREN ABD 3 PROSTH EACH 34847 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305906 RADIOLOGY - IR VISC & INFRAREN ABD 4+ PROST EACH 34848 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32305807 RADIOLOGY - IR XPOSE FOR ENDOPROSTH FEMORL EACH 34812 "$18,073.00 " 510 "$12,651.10 " "$9,036.50 " "$14,458.40 " 65% 80% 50% 50% 65% Non Payable Non Payable 32303893 RADIOLOGY - IR XR ABSC SINUS/FISTULA S&I EACH 76080 "$1,365.00 " 320 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $168.20 $168.20 $56.32 65% of Billed Charges 65% of Billed Charges 32303240 RADIOLOGY - IR XR ANG VISCERAL W/WO FLUSH S& EACH 75726 "$13,588.00 " 323 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $175.15 65% of Billed Charges 65% of Billed Charges 32303265 RADIOLOGY - IR XR ANGIO ADRENAL BILATERAL S&I EACH 75733 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $166.81 65% of Billed Charges 65% of Billed Charges 32303257 RADIOLOGY - IR XR ANGIO ADRENAL UNILAT S&I EACH 75731 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $154.35 65% of Billed Charges 65% of Billed Charges 32303216 RADIOLOGY - IR XR ANGIO EXTREMITY BILAT S&I EACH 75716 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $168.76 65% of Billed Charges 65% of Billed Charges 32303208 RADIOLOGY - IR XR ANGIO EXTREMITY UNILAT S&I EACH 75710 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $159.17 65% of Billed Charges 65% of Billed Charges 32303315 RADIOLOGY - IR XR ANGIO INTERNAL MAMMARY S&I EACH 75756 "$7,882.00 " 320 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $156.94 65% of Billed Charges 65% of Billed Charges 32303307 RADIOLOGY - IR XR ANGIO PULMONARY NONSEL S&I EACH 75746 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges $555.30 $555.30 $136.93 65% of Billed Charges 65% of Billed Charges 32303299 RADIOLOGY - IR XR ANGIO PULMONARY SEL BI S&I EACH 75743 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $153.56 65% of Billed Charges 65% of Billed Charges 32303281 RADIOLOGY - IR XR ANGIO PULMONARY SEL UNI S&I EACH 75741 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $135.99 65% of Billed Charges 65% of Billed Charges 32303323 RADIOLOGY - IR XR ANGIO SEL EA ADD VESSEL S& EACH 75774 "$1,378.00 " 323 $964.60 $689.00 "$1,102.40 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $103.24 65% of Billed Charges 65% of Billed Charges 32303273 RADIOLOGY - IR XR ANGIOGRAM PELVIC S&I EACH 75736 "$13,588.00 " 323 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $143.77 65% of Billed Charges 65% of Billed Charges 32303190 RADIOLOGY - IR XR ANGIOGRAM SPINAL SELECT S& EACH 75705 "$13,588.00 " 323 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $244.44 65% of Billed Charges 65% of Billed Charges 32303091 RADIOLOGY - IR XR AORTOGRAM ABD W LOW EXT S&I EACH 75630 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $164.11 65% of Billed Charges 65% of Billed Charges 32303083 RADIOLOGY - IR XR AORTOGRAM ABD W/SER S&I EACH 75625 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $134.67 65% of Billed Charges 65% of Billed Charges 32303067 RADIOLOGY - IR XR AORTOGRAM THORACIC S&I EACH 75600 "$7,882.00 " 323 "$5,517.40 " "$3,941.00 " "$6,305.60 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $190.57 65% of Billed Charges 65% of Billed Charges 32303075 RADIOLOGY - IR XR AORTOGRM THORACIC W SER S& EACH 75605 "$13,588.00 " 323 "$9,511.60 " "$6,794.00 " "$10,870.40 " 65% of Billed Charges 80% of Billed Charges "$1,569.89 " "$1,569.89 " $124.14 65% of Billed Charges 65% of Billed Charges 32302804 RADIOLOGY - IR XR ARTHROGRAM ANKLE S&I EACH 73615 $951.00 322 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $121.61 65% of Billed Charges 65% of Billed Charges 32308769 RADIOLOGY - IR XR ARTHROGRAM ANKLE S&I LT EACH 73615 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $121.61 65% of Billed Charges 65% of Billed Charges 32308777 RADIOLOGY - IR XR ARTHROGRAM ANKLE S&I RT EACH 73615 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $121.61 65% of Billed Charges 65% of Billed Charges 32308645 RADIOLOGY - IR XR ARTHROGRAM ELBOW S&I LT EACH 73085 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $107.26 65% of Billed Charges 65% of Billed Charges 32308652 RADIOLOGY - IR XR ARTHROGRAM ELBOW S&I RT EACH 73085 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $107.26 65% of Billed Charges 65% of Billed Charges 32304180 RADIOLOGY - IR XR ARTHROGRAM HIP BIL S&I EACH 73525 $951.00 322 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $116.94 65% of Billed Charges 65% of Billed Charges 32308728 RADIOLOGY - IR XR ARTHROGRAM HIP S&I LT EACH 73525 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $116.94 65% of Billed Charges 65% of Billed Charges 32308736 RADIOLOGY - IR XR ARTHROGRAM HIP S&I RT EACH 73525 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $116.94 65% of Billed Charges 65% of Billed Charges 32304198 RADIOLOGY - IR XR ARTHROGRAM KNEE BIL S&I EACH 73580 $951.00 322 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $129.29 65% of Billed Charges 65% of Billed Charges 32308744 RADIOLOGY - IR XR ARTHROGRAM KNEE S&I LT EACH 73580 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $129.29 65% of Billed Charges 65% of Billed Charges 32308751 RADIOLOGY - IR XR ARTHROGRAM KNEE S&I RT EACH 73580 $951.00 320 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $129.29 65% of Billed Charges 65% of Billed Charges 32304206 RADIOLOGY - IR XR ARTHROGRAM SHOULDER BIL S&I EACH 73040 $951.00 322 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $212.26 $212.26 $113.72 65% of Billed Charges 65% of Billed Charges 40100257 RADIOLOGY - MAMMO BREAST TOMOSYNTHESIS - LEFT EACH 77061 $350.00 614 $245.00 $175.00 $280.00 65% of Billed Charges 80% of Billed Charges $96.23 $96.23 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 40100265 RADIOLOGY - MAMMO BREAST TOMOSYNTHESIS - RIGHT EACH 77061 $350.00 614 $245.00 $175.00 $280.00 65% of Billed Charges 80% of Billed Charges $96.23 $96.23 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 40100273 RADIOLOGY - MAMMO BREAST TOMOSYNTHESIS-BILATERAL EACH 77062 $700.00 614 $490.00 $350.00 $560.00 65% of Billed Charges 80% of Billed Charges $75.33 $75.33 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 40101214 RADIOLOGY - MAMMO BX BREAST 1ST LES MRI EACH 19085 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 40101107 RADIOLOGY - MAMMO BX BREAST 1ST LES US EACH 19083 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 40101032 RADIOLOGY - MAMMO BX BREAST 2ND LES STEREO EACH 19082 $773.00 510 $541.10 $386.50 $618.40 65% 80% 50% 50% 65% Non Payable Non Payable 40101289 RADIOLOGY - MAMMO BX BREAST ADDL LES MRI EACH 19086 $387.00 510 $270.90 $193.50 $309.60 65% 80% 50% 50% 65% Non Payable Non Payable 40101172 RADIOLOGY - MAMMO BX BREAST ADDL LES US EACH 19084 $387.00 510 $270.90 $193.50 $309.60 65% 80% 50% 50% 65% Non Payable Non Payable 40101354 RADIOLOGY - MAMMO BX BREAST NDL 1 LES EACH 19100 "$4,009.00 " 510 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% 80% 50% 50% 65% Non Payable Non Payable 40100000 RADIOLOGY - MAMMO MAMM DUCTOGRAM MULTIPLE S&I EACH 77054 $606.00 320 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $168.20 $168.20 $69.48 65% of Billed Charges 65% of Billed Charges 40100018 RADIOLOGY - MAMMO MAMMARY DUCTOGRAM SINGLE S&I EACH 77053 $606.00 320 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $168.20 $168.20 $53.88 65% of Billed Charges 65% of Billed Charges 40100034 RADIOLOGY - MAMMO MAMMO GUIDE NDL BRST EACH 19281 "$4,009.00 " 401 "$2,806.30 " "$2,004.50 " "$3,207.20 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $94.81 Non Payable Non Payable 40100158 RADIOLOGY - MAMMO MAMMO SCREENING UNILAT LT EACH 77067 $275.00 403 $192.50 $137.50 $220.00 65% of Billed Charges 80% of Billed Charges $74.19 $74.19 $129.74 Non Payable Non Payable 40100133 RADIOLOGY - MAMMO MAMMO SCREENING UNILAT RT EACH 77067 $275.00 403 $192.50 $137.50 $220.00 65% of Billed Charges 80% of Billed Charges $74.19 $74.19 $129.74 Non Payable Non Payable 40100075 RADIOLOGY - MAMMO MAMMOGRAM DIAGNOSTIC BILAT EACH 77066 $259.00 401 $181.30 $129.50 $207.20 65% of Billed Charges 80% of Billed Charges $89.78 $89.78 $159.54 Non Payable Non Payable 40100083 RADIOLOGY - MAMMO MAMMOGRAM DIAGNOSTIC UNILAT EACH 77065 $255.00 401 $178.50 $127.50 $204.00 65% of Billed Charges 80% of Billed Charges $70.44 $70.44 $127.02 Non Payable Non Payable 40100109 RADIOLOGY - MAMMO MAMMOGRAM SCREENING BILAT EACH 77067 $413.00 403 $289.10 $206.50 $330.40 65% of Billed Charges 80% of Billed Charges $74.19 $74.19 $129.74 Non Payable Non Payable 40101453 RADIOLOGY - MAMMO SAVI CLIP EACH A4648 "$1,000.00 " 278 $700.00 $500.00 $800.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 40100281 RADIOLOGY - MAMMO SCREENING BREAST TOMOSYN-BILAT EACH 77063 $484.00 403 $338.80 $242.00 $387.20 65% of Billed Charges 80% of Billed Charges $20.62 $20.62 $51.98 Non Payable Non Payable 40100216 RADIOLOGY - MAMMO US BREAST COMPLETE EACH 76641 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $73.33 $73.33 $101.18 Non Payable Non Payable 40100232 RADIOLOGY - MAMMO US BREAST LIMITED EACH 76642 $225.00 402 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $73.33 $73.33 $82.88 Non Payable Non Payable 62900006 RADIOLOGY - MRI CONTRAST MRI GAD-BASE INJ 1ML EACH A9579 $9.00 255 $6.30 $4.50 $7.20 65% 80% 50% 50% 65% 65% 65% 62900105 RADIOLOGY - MRI MRA ABDOMEN EACH 74185 $606.00 618 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $362.29 $362.29 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900121 RADIOLOGY - MRI MRA CHEST W/CONTRAST EACH 71555 "$1,308.00 " 618 $915.60 $654.00 "$1,046.40 " 65% of Billed Charges 80% of Billed Charges $363.45 $363.45 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900154 RADIOLOGY - MRI MRA HEAD W&W/O CON EACH 70546 $951.00 615 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900162 RADIOLOGY - MRI MRA HEAD W/CON EACH 70545 $951.00 615 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900170 RADIOLOGY - MRI MRA HEAD W/O CON EACH 70544 $606.00 615 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901087 RADIOLOGY - MRI MRA LOWER EXT EACH 73725 $951.00 616 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $364.89 $364.89 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901285 RADIOLOGY - MRI MRA LWR EXT EACH 73725 $951.00 616 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $364.89 $364.89 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900246 RADIOLOGY - MRI MRA NECK W&W/O CON EACH 70549 $951.00 615 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900253 RADIOLOGY - MRI MRA NECK W/CON EACH 70548 $951.00 615 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900261 RADIOLOGY - MRI MRA NECK W/O CON EACH 70547 $606.00 615 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900295 RADIOLOGY - MRI MRA PELVIS W/CONTRAST EACH 72198 $951.00 618 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $364.31 $364.31 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900311 RADIOLOGY - MRI MRA SPINE W/ OR W/O CONTRAST EACH 72159 "$1,460.40 " 618 "$1,022.28 " $730.20 "$1,168.32 " 65% of Billed Charges 80% of Billed Charges $436.19 $436.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900329 RADIOLOGY - MRI MRA UPR EXT EACH 73225 $606.00 618 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $436.19 $436.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901129 RADIOLOGY - MRI MRA UPR EXT W OR W/O CON BIL EACH 73225 "$3,911.00 " 618 "$2,737.70 " "$1,955.50 " "$3,128.80 " 65% of Billed Charges 80% of Billed Charges $436.19 $436.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901103 RADIOLOGY - MRI MRA UPR EXT W OR W/O CON LT EACH 73225 "$2,607.00 " 618 "$1,824.90 " "$1,303.50 " "$2,085.60 " 65% of Billed Charges 80% of Billed Charges $436.19 $436.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900352 RADIOLOGY - MRI MRI ABDOMEN W&WO CONTRAST EACH 74183 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900378 RADIOLOGY - MRI MRI ABDOMEN W/O CONTRAST EACH 74181 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900410 RADIOLOGY - MRI MRI BRAIN W&W/O CON EACH 70553 $951.00 611 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900428 RADIOLOGY - MRI MRI BRAIN W/CON EACH 70552 $951.00 611 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900436 RADIOLOGY - MRI MRI BRAIN W/O CON EACH 70551 $606.00 611 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901400 RADIOLOGY - MRI MRI BREAST W/O CONTRAST BI EACH 77047 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $184.45 $184.45 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901418 RADIOLOGY - MRI MRI BREAST W/O CONTRAST LT EACH 77046 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $184.45 $184.45 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901426 RADIOLOGY - MRI MRI BREAST W/O CONTRAST RT EACH 77046 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $184.45 $184.45 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901343 RADIOLOGY - MRI MRI BREAST W/WO CONTRAST BI EACH 77049 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $234.40 $234.40 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901384 RADIOLOGY - MRI MRI BREAST W/WO CONTRAST LT EACH 77048 $455.00 614 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $235.55 $235.55 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901392 RADIOLOGY - MRI MRI BREAST W/WO CONTRAST RT EACH 77048 $455.00 614 $318.50 $227.50 $364.00 65% of Billed Charges 80% of Billed Charges $235.55 $235.55 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900550 RADIOLOGY - MRI MRI CARD W/O&W CON STRESS EACH 75563 "$1,980.00 " 614 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900576 RADIOLOGY - MRI MRI CARDIAC W/O CONTRAST EACH 75557 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900592 RADIOLOGY - MRI MRI CARDIAC W/O&W CONTRAST EACH 75561 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900600 RADIOLOGY - MRI MRI CERVICAL SP W&WO CONTRAST EACH 72156 $951.00 612 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900618 RADIOLOGY - MRI MRI CERVICAL SP WO CONTRAST EACH 72141 $606.00 612 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900626 RADIOLOGY - MRI MRI CERVICAL SPINE W/CONTRAST EACH 72142 $951.00 612 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900634 RADIOLOGY - MRI MRI CHEST W&W/O CONTRAST EACH 71552 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900642 RADIOLOGY - MRI MRI CHEST W/CONTRAST EACH 71551 "$1,980.00 " 614 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900659 RADIOLOGY - MRI MRI CHEST W/O CONTRAST EACH 71550 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901251 RADIOLOGY - MRI MRI LOW EXTREM JOINT W/CON BIL EACH 73722 "$1,980.00 " 614 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901244 RADIOLOGY - MRI MRI LOW EXTREM JOINT W/CON LT EACH 73722 "$1,980.00 " 614 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900709 RADIOLOGY - MRI MRI LOW EXTREM JOINT W/CON RT EACH 73722 "$1,980.00 " 614 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900717 RADIOLOGY - MRI MRI LUMBAR SP W&WO CONTRAST EACH 72158 $951.00 612 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900725 RADIOLOGY - MRI MRI LUMBAR SPINE W/CONTRAST EACH 72149 $951.00 612 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900733 RADIOLOGY - MRI MRI LUMBAR SPINE W/O CONTRAST EACH 72148 $606.00 612 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900741 RADIOLOGY - MRI MRI LWR EXT JNT W/O CON BIL EACH 73721 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900758 RADIOLOGY - MRI MRI LWR EXT JNT W/O CON LT EACH 73721 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900667 RADIOLOGY - MRI MRI LWR EXT JNT W/O CON RT EACH 73721 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900766 RADIOLOGY - MRI MRI LWR EXT W&W/O CON BIL EACH 73720 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900774 RADIOLOGY - MRI MRI LWR EXT W&W/O CON LT EACH 73720 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900675 RADIOLOGY - MRI MRI LWR EXT W&W/O CON RT EACH 73720 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900782 RADIOLOGY - MRI MRI LWR EXT W/CON BIL EACH 73719 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900790 RADIOLOGY - MRI MRI LWR EXT W/CON LT EACH 73719 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900808 RADIOLOGY - MRI MRI LWR EXT W/O CON BIL EACH 73718 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900816 RADIOLOGY - MRI MRI LWR EXT W/O CON LT EACH 73718 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900691 RADIOLOGY - MRI MRI LWR EXT W/O CON RT EACH 73718 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901277 RADIOLOGY - MRI MRI LWR EXTR JOINT W&WO CON BI EACH 73723 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901269 RADIOLOGY - MRI MRI LWR EXTR JOINT W&WO CON LT EACH 73723 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900824 RADIOLOGY - MRI MRI LWR EXTR JOINT W&WO CON RT EACH 73723 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900832 RADIOLOGY - MRI MRI ORBIT/FACE/NECK W&W/O CON EACH 70543 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900840 RADIOLOGY - MRI MRI ORBIT/FACE/NECK W/CON EACH 70542 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900857 RADIOLOGY - MRI MRI ORBIT/FACE/NECK W/O CON EACH 70540 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900865 RADIOLOGY - MRI MRI PELVIS W&W/O CONTRAST EACH 72197 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900873 RADIOLOGY - MRI MRI PELVIS W/CONTRAST EACH 72196 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900881 RADIOLOGY - MRI MRI PELVIS W/O CONTRAST EACH 72195 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901319 RADIOLOGY - MRI MRI PROSTATE W SPECTROSCO EACH 76498 $225.00 610 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900899 RADIOLOGY - MRI MRI SPECTROSCOPY EACH 76390 $225.00 610 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $279.15 $279.15 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900907 RADIOLOGY - MRI MRI THORACIC SP W&WO CONTRAST EACH 72157 $951.00 612 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900923 RADIOLOGY - MRI MRI THORACIC SPINE W/CONTRAST EACH 72147 $951.00 612 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900949 RADIOLOGY - MRI MRI TMJ UNILAT OR BILAT EACH 70336 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901194 RADIOLOGY - MRI MRI UP EXTREMITY W&WO CON BIL EACH 73220 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901020 RADIOLOGY - MRI MRI UP EXTREMITY W&WO CON LT EACH 73220 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901186 RADIOLOGY - MRI MRI UP EXTREMITY W/CON 50 EACH 73219 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901178 RADIOLOGY - MRI MRI UP EXTREMITY W/CON LT EACH 73219 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900972 RADIOLOGY - MRI MRI UP EXTREMITY W/CON RT EACH 73219 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901160 RADIOLOGY - MRI MRI UP EXTREMITY W/O CON BIL EACH 73218 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901152 RADIOLOGY - MRI MRI UP EXTREMITY W/O CON LT EACH 73218 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901038 RADIOLOGY - MRI MRI UP EXTREMITY W/O CON RT EACH 73218 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901236 RADIOLOGY - MRI MRI UP EXTREMITYJOINT W&WO BIL EACH 73223 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901228 RADIOLOGY - MRI MRI UP EXTREMITYJOINT W&WO LT EACH 73223 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900980 RADIOLOGY - MRI MRI UP EXTREMITYJOINT W&WO RT EACH 73223 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $428.34 $428.34 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901210 RADIOLOGY - MRI MRI UPPER EXT JOINT W/CON BIL EACH 73222 "$1,980.00 " 614 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901202 RADIOLOGY - MRI MRI UPPER EXT JOINT W/CON LT EACH 73222 "$1,980.00 " 614 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900956 RADIOLOGY - MRI MRI UPPER EXT JOINT W/CON RT EACH 73222 "$1,980.00 " 614 "$1,386.00 " $990.00 "$1,584.00 " 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900998 RADIOLOGY - MRI MRI UPR EXT JNT W/O CON BILAT EACH 73221 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901004 RADIOLOGY - MRI MRI UPR EXT JNT W/O CON LT EACH 73221 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62901012 RADIOLOGY - MRI MRI UPR EXT JNT W/O CON RT EACH 73221 $606.00 614 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 34001909 RADIOLOGY - NM DEXA BONE DENSITY AXIAL EACH 77080 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $58.00 $58.00 $37.40 65% of Billed Charges 65% of Billed Charges 34002048 RADIOLOGY - NM DEXA W/VERTEBRAL FRACTURE ASSM EACH 77085 $272.00 320 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $75.98 $75.98 $50.32 65% of Billed Charges 65% of Billed Charges 34001974 RADIOLOGY - NM GASTROESOPHAGEAL REFLUX STUDY EACH 78262 "$1,020.00 " 340 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $230.49 Non Payable Non Payable 34001966 RADIOLOGY - NM GATED HEART PLANAR SINGLE EACH 78472 "$1,020.00 " 340 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $218.52 Non Payable Non Payable 34001925 RADIOLOGY - NM HEPATOBIL SYST IMAGE W/DRUG EACH 78227 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $425.00 Non Payable Non Payable 34000356 RADIOLOGY - NM HEPATOBIL SYST IMAGE W/O DRUG EACH 78226 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $314.53 Non Payable Non Payable 34002113 RADIOLOGY - NM HT MUSCLE IMAGE SPECT SING EACH 78451 "$3,511.00 " 340 "$2,457.70 " "$1,755.50 " "$2,808.80 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $322.81 Non Payable Non Payable 34002030 RADIOLOGY - NM LUNG PERF & VENT DIFFERENTIAL EACH 78598 "$1,337.00 " 340 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $291.73 Non Payable Non Payable 34002097 RADIOLOGY - NM LUNG VENT & PERFUS IMAGING EACH 78582 "$1,337.00 " 340 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $320.10 Non Payable Non Payable 34001933 RADIOLOGY - NM LUNG VENTILATION IMAGING EACH 78579 "$1,020.00 " 340 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $179.78 Non Payable Non Payable 34000521 RADIOLOGY - NM NM BONE LIMITED EACH 78300 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $219.98 Non Payable Non Payable 34000133 RADIOLOGY - NM NM BONE MARROW LIMITED EACH 78102 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $163.37 Non Payable Non Payable 34000141 RADIOLOGY - NM NM BONE MARROW MULTIPLE EACH 78103 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $208.12 Non Payable Non Payable 34000158 RADIOLOGY - NM NM BONE MARROW WHOLE BODY EACH 78104 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $239.72 Non Payable Non Payable 34000539 RADIOLOGY - NM NM BONE MULTIPLE AREAS EACH 78305 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $266.72 Non Payable Non Payable 34000547 RADIOLOGY - NM NM BONE WHOLE BODY EACH 78306 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $289.60 Non Payable Non Payable 34000927 RADIOLOGY - NM NM BRAIN MIN 4 STATIC VIEWS EACH 78605 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $191.98 Non Payable Non Payable 34000950 RADIOLOGY - NM NM BRAIN VASCULAR FLOW ONLY EACH 78610 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $166.68 Non Payable Non Payable 34000919 RADIOLOGY - NM NM BRAIN W FLOW < 4 V STATIC EACH 78601 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $208.35 Non Payable Non Payable 34000935 RADIOLOGY - NM NM BRAIN W FLOW MIN 4VW STATIC EACH 78606 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $316.96 Non Payable Non Payable 34002105 RADIOLOGY - NM NM CARDIAC AVID INFARCT STUDY EACH 78469 "$1,337.00 " 340 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $214.57 Non Payable Non Payable 34001750 RADIOLOGY - NM NM COBALT 57 PO DX UP TO 1 UCI EACH A9559 $40.00 343 $28.00 $20.00 $32.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $70.33 Non Payable Non Payable 34001651 RADIOLOGY - NM NM COBALT 57/58 CYANOCO 1UCI EACH A9546 $801.00 343 $560.70 $400.50 $640.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $0.84 Non Payable Non Payable 34000968 RADIOLOGY - NM NM CSF CISTERNOGRAM EACH 78630 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $323.93 Non Payable Non Payable 34001727 RADIOLOGY - NM NM GALLIUM GA-67 PER MCI EACH A9556 $56.00 343 $39.20 $28.00 $44.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $115.36 Non Payable Non Payable 34000422 RADIOLOGY - NM NM GASTRIC EMPTYING EACH 78264 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $319.15 Non Payable Non Payable 34000471 RADIOLOGY - NM NM GI BLOOD LOSS EACH 78278 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $334.53 Non Payable Non Payable 34000661 RADIOLOGY - NM NM HRT MUSC IMAGE EACH 78454 "$3,511.00 " 341 "$2,457.70 " "$1,755.50 " "$2,808.80 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $416.51 Non Payable Non Payable 34000653 RADIOLOGY - NM NM HRT MUSCLE IMAGE EACH 78453 "$3,511.00 " 341 "$2,457.70 " "$1,755.50 " "$2,808.80 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $290.80 Non Payable Non Payable 34000687 RADIOLOGY - NM NM HRT MUSCLE IMAGE SPECT MULT EACH 78452 "$3,511.00 " 341 "$2,457.70 " "$1,755.50 " "$2,808.80 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $450.49 Non Payable Non Payable 34001446 RADIOLOGY - NM NM I 123 CAP 100UCI EACH A9516 $83.00 343 $58.10 $41.50 $66.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $87.46 Non Payable Non Payable 34001503 RADIOLOGY - NM NM I-131 CAP DX MCI EACH A9528 $52.00 343 $36.40 $26.00 $41.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $82.12 Non Payable Non Payable 34001453 RADIOLOGY - NM NM I-131 CAP TX MCI EACH A9517 $56.00 344 $39.20 $28.00 $44.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $44.72 Non Payable Non Payable 34001537 RADIOLOGY - NM NM I-131 SOD IOD DX PER UCI EACH A9531 $10.00 343 $7.00 $5.00 $8.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $3.66 Non Payable Non Payable 34001511 RADIOLOGY - NM NM I-131 SOL DX MCI EACH A9529 $32.00 343 $22.40 $16.00 $25.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $0.76 Non Payable Non Payable 34001529 RADIOLOGY - NM NM I-131 SOL TX PER MCI EACH A9530 $53.00 344 $37.10 $26.50 $42.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $9.56 Non Payable Non Payable 34001396 RADIOLOGY - NM NM IN- III CAPROPE DX UP T0 10 EACH A9507 "$3,482.00 " 343 "$2,437.40 " "$1,741.00 " "$2,785.60 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" "$4,220.17 " Non Payable Non Payable 34001669 RADIOLOGY - NM NM INDIUM III 0.5 MCI EACH A9547 "$1,249.00 " 343 $874.30 $624.50 $999.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" "$1,716.60 " Non Payable Non Payable 34001677 RADIOLOGY - NM NM INDIUM III PENTETATE/0.5MCI EACH A9548 "$1,051.00 " 343 $735.70 $525.50 $840.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $396.66 Non Payable Non Payable 34001859 RADIOLOGY - NM NM INDIUM III WBC DX PER DOSE EACH A9570 "$1,681.00 " 343 "$1,176.70 " $840.50 "$1,344.80 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" "$3,433.20 " Non Payable Non Payable 34001875 RADIOLOGY - NM NM IN-III PENTETREO/DOSE TO 6 EACH A9572 "$2,717.00 " 343 "$1,901.90 " "$1,358.50 " "$2,173.60 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" "$5,448.96 " Non Payable Non Payable 34000497 RADIOLOGY - NM NM INTESTINE MUCOSA/MECKELS EACH 78290 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $316.59 Non Payable Non Payable 34001412 RADIOLOGY - NM NM ISOTOPE I-123 DX PER MCI EACH A9509 $531.00 343 $371.70 $265.50 $424.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $244.67 Non Payable Non Payable 34001842 RADIOLOGY - NM NM ISOTOPE TC99M EXAM DX DOSE EACH A9569 "$1,840.00 " 343 "$1,288.00 " $920.00 "$1,472.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" "$1,467.62 " Non Payable Non Payable 34001065 RADIOLOGY - NM NM KIDNEY FLO&FUN MULT W/WO RX EACH 78709 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $351.81 Non Payable Non Payable 34001057 RADIOLOGY - NM NM KIDNEY FLOW&FUNC SING W RX EACH 78708 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $170.46 Non Payable Non Payable 34001024 RADIOLOGY - NM NM KIDNEY SCAN MORPHOLOGY EACH 78700 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $164.14 Non Payable Non Payable 34001032 RADIOLOGY - NM NM KIDNEY SCAN W/FLOW EACH 78701 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $210.04 Non Payable Non Payable 34001040 RADIOLOGY - NM NM KIDNEY SCAN W/FLOW&FUNCT EACH 78707 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $224.09 Non Payable Non Payable 34000323 RADIOLOGY - NM NM LIVER & SPLEEN STATIC EACH 78215 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $188.01 Non Payable Non Payable 34000299 RADIOLOGY - NM NM LIVER W/ VASCULAR FLOW EACH 78202 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $197.67 Non Payable Non Payable 34000331 RADIOLOGY - NM NM LIVER&SPLEEN W/VASC FLOW EACH 78216 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $124.53 Non Payable Non Payable 34000273 RADIOLOGY - NM NM LYMPH SYSTEM EACH 78195 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $340.33 Non Payable Non Payable 34001362 RADIOLOGY - NM NM MDP PER STUDY UP TO 30MCI EACH A9503 $55.00 343 $38.50 $27.50 $44.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $12.48 Non Payable Non Payable 34001404 RADIOLOGY - NM NM MIBG PER 0.5MCI EACH A9508 "$2,491.00 " 343 "$1,743.70 " "$1,245.50 " "$1,992.80 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $764.38 Non Payable Non Payable 34001354 RADIOLOGY - NM NM MYOVIEW PER DOSE EACH A9502 $255.00 343 $178.50 $127.50 $204.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $93.56 Non Payable Non Payable 34000117 RADIOLOGY - NM NM PARATHYROID EACH 78070 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $284.43 Non Payable Non Payable 34001438 RADIOLOGY - NM NM PERTECH PER MCI EACH A9512 $5.00 343 $3.50 $2.50 $4.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $10.69 Non Payable Non Payable 34000802 RADIOLOGY - NM NM PULMONARY PERFUSION PART EACH 78580 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $226.87 Non Payable Non Payable 34001255 RADIOLOGY - NM NM RADIOPAHARM THERAPY IV EACH 79101 $616.00 342 $431.20 $308.00 $492.80 65% of Billed Charges 80% of Billed Charges $174.48 $174.48 $142.04 Non Payable Non Payable 34001248 RADIOLOGY - NM NM RADIOPAHARM THERAPY ORAL EACH 79005 $616.00 342 $431.20 $308.00 $492.80 65% of Billed Charges 80% of Billed Charges $174.48 $174.48 $131.84 Non Payable Non Payable 34001339 RADIOLOGY - NM NM SESTAMIBI DX PER DOSE EACH A9500 $293.00 343 $205.10 $146.50 $234.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $102.48 Non Payable Non Payable 34001891 RADIOLOGY - NM NM SM 153 LEXI PER TRTM DOSE EACH A9604 "$44,790.00 " 344 "$31,353.00 " "$22,395.00 " "$35,832.00 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" "$15,631.57 " Non Payable Non Payable 34000240 RADIOLOGY - NM NM SPLEEN EACH 78185 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $164.13 Non Payable Non Payable 34001883 RADIOLOGY - NM NM STRONTIUM PER MCI EACH A9600 "$10,787.00 " 344 "$7,550.90 " "$5,393.50 " "$8,629.60 " 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" "$3,600.00 " Non Payable Non Payable 34001834 RADIOLOGY - NM NM TC99M ARCITUMOMAB/DOSE TO45 EACH A9568 $181.00 343 $126.70 $90.50 $144.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" "$1,040.00 " Non Payable Non Payable 34001735 RADIOLOGY - NM NM TC99M BICISAT/DOSE TO 25MCI EACH A9557 $812.00 343 $568.40 $406.00 $649.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $357.21 Non Payable Non Payable 34001552 RADIOLOGY - NM NM TC99M DEPREOTID UP TO 35MCI EACH A9536 $121.00 343 $84.70 $60.50 $96.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" "$1,120.00 " Non Payable Non Payable 34001420 RADIOLOGY - NM NM TC99M DISOFENIN DX UP TO 15 EACH A9510 $129.00 343 $90.30 $64.50 $103.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $67.20 Non Payable Non Payable 34001826 RADIOLOGY - NM NM TC99M DX AER PENTETATE/DOSE EACH A9567 $85.00 343 $59.50 $42.50 $68.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $17.72 Non Payable Non Payable 34001586 RADIOLOGY - NM NM TC99M DX PENTET UP TO 25MCI EACH A9539 $62.00 343 $43.40 $31.00 $49.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $30.08 Non Payable Non Payable 34001685 RADIOLOGY - NM NM TC99M GLUCEPTAT UP TO 25MCI EACH A9550 $79.00 343 $55.30 $39.50 $63.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $20.33 Non Payable Non Payable 34001594 RADIOLOGY - NM NM TC99M MAC ALBUMIN UPTO 10 EACH A9540 $58.00 343 $40.60 $29.00 $46.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $28.80 Non Payable Non Payable 34001560 RADIOLOGY - NM NM TC99M MEBROFEN UP TO 15MCI EACH A9537 $102.00 343 $71.40 $51.00 $81.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $53.10 Non Payable Non Payable 34001784 RADIOLOGY - NM NM TC99M MERTIATIDE/DOSE TO 15 EACH A9562 $325.00 343 $227.50 $162.50 $260.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $629.95 Non Payable Non Payable 34001776 RADIOLOGY - NM NM TC99M OXYDRONATE/DOSE TO 30 EACH A9561 $54.00 343 $37.80 $27.00 $43.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $42.24 Non Payable Non Payable 34001578 RADIOLOGY - NM NM TC99M PYROPHOSP UP TO 25MCI EACH A9538 $78.00 343 $54.60 $39.00 $62.40 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $48.00 Non Payable Non Payable 34001768 RADIOLOGY - NM NM TC99M RBC PER DOSE TO 30MCI EACH A9560 $90.00 343 $63.00 $45.00 $72.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $89.66 Non Payable Non Payable 34001693 RADIOLOGY - NM NM TC99M SUCCIMER UP TO 10 EACH A9551 $241.00 343 $168.70 $120.50 $192.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $408.91 Non Payable Non Payable 34001602 RADIOLOGY - NM NM TC99M SULF COLLOID UP TO 20 EACH A9541 $84.00 343 $58.80 $42.00 $67.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $256.67 Non Payable Non Payable 34001115 RADIOLOGY - NM NM TESTICULAR IMAG W/FLOW EACH 78761 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $203.76 Non Payable Non Payable 34000091 RADIOLOGY - NM NM THYROID CA METS WHOLE BODY EACH 78018 "$1,337.00 " 341 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $300.40 Non Payable Non Payable 34001131 RADIOLOGY - NM NM TUMOR LOCALIZATION LIMITED EACH 78800 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $248.55 Non Payable Non Payable 34001164 RADIOLOGY - NM NM TUMOR LOCALIZATION SPECT EACH 78803 "$3,511.00 " 341 "$2,457.70 " "$1,755.50 " "$2,808.80 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $372.81 Non Payable Non Payable 34001156 RADIOLOGY - NM NM TUMOR LOCALIZATION WB EACH 78802 "$3,511.00 " 341 "$2,457.70 " "$1,755.50 " "$2,808.80 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $299.45 Non Payable Non Payable 34001149 RADIOLOGY - NM NM TUMOR LOCALIZE MULTIPLE EACH 78801 "$1,020.00 " 341 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $273.37 Non Payable Non Payable 34001172 RADIOLOGY - NM NM TUMR LOC 2 OR > DAYS WB EACH 78804 "$3,511.00 " 341 "$2,457.70 " "$1,755.50 " "$2,808.80 " 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges $632.63 Non Payable Non Payable 34001743 RADIOLOGY - NM NM XENON XE-133 PER 10MCI EACH A9558 $70.00 343 $49.00 $35.00 $56.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $201.32 Non Payable Non Payable 34002006 RADIOLOGY - NM PARATHYROID PLANAR (SPECT) EACH 78071 "$1,020.00 " 340 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $339.33 Non Payable Non Payable 34002014 RADIOLOGY - NM PARATHYROID PLANR (SPECT) W/CT EACH 78072 "$1,337.00 " 340 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $480.14 Non Payable Non Payable 34001388 RADIOLOGY - NM "THALLIUM 201, DX PER MCI " EACH A9505 $80.00 343 $56.00 $40.00 $64.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $146.31 Non Payable Non Payable 34001982 RADIOLOGY - NM THYROID IMAGING EACH 78013 "$1,020.00 " 340 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $183.96 Non Payable Non Payable 34001990 RADIOLOGY - NM THYROID IMAGING W/UPTAKE(S) EACH 78014 "$1,020.00 " 340 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $230.38 Non Payable Non Payable 34002022 RADIOLOGY - NM THYROID UPTAKE EACH 78012 "$1,020.00 " 340 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $78.68 Non Payable Non Payable 34001958 RADIOLOGY - NM VENOGRAM - BILATERAL EACH 78458 "$1,020.00 " 340 $714.00 $510.00 $816.00 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $197.57 Non Payable Non Payable 34001941 RADIOLOGY - NM VENOGRAM - UNILATERAL EACH 78457 "$1,337.00 " 340 $935.90 $668.50 "$1,069.60 " 65% of Billed Charges 80% of Billed Charges $319/visit $290/visit $168.44 Non Payable Non Payable 40400210 RADIOLOGY - PET GALLIUM GA-68 DOTATATE 0.1 MCI EACH A9587 $60.00 343 $42.00 $30.00 $48.00 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $62.22 Non Payable Non Payable 40400004 RADIOLOGY - PET PET BRAIN IMAGE METABOLIC EVAL EACH 78608 "$3,869.00 " 404 "$2,708.30 " "$1,934.50 " "$3,095.20 " 65% of Billed Charges 80% of Billed Charges $829.87 $829.87 "$1,300.00 " Non Payable Non Payable 40400012 RADIOLOGY - PET PET BRAIN IMAGING PERF EVAL EACH 78609 $436.80 404 $305.76 $218.40 $349.44 65% of Billed Charges 80% of Billed Charges $61.49 $61.49 "$1,300.00 " Non Payable Non Payable 40400020 RADIOLOGY - PET PET BREAST CANCER INITIAL DIAG EACH G0252 "$4,716.00 " 404 "$3,301.20 " "$2,358.00 " "$3,772.80 " 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable "$1,300.00 " Non Payable Non Payable 40400038 RADIOLOGY - PET PET F-18 FDG/DOSE UP TO 45MCI EACH A9552 $716.00 343 $501.20 $358.00 $572.80 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $230.33 Non Payable Non Payable 40400046 RADIOLOGY - PET PET MYOCARD METABOLIC EVAL EACH 78459 "$3,511.00 " 404 "$2,457.70 " "$1,755.50 " "$2,808.80 " 65% of Billed Charges 80% of Billed Charges "$1,146.30 " "$1,146.30 " "$1,300.00 " Non Payable Non Payable 40400053 RADIOLOGY - PET PET MYOCARD PERF MULTI STUDIES EACH 78492 "$3,869.00 " 404 "$2,708.30 " "$1,934.50 " "$3,095.20 " 65% of Billed Charges 80% of Billed Charges "$1,146.30 " "$1,146.30 " "$1,300.00 " Non Payable Non Payable 40400061 RADIOLOGY - PET PET MYOCARD PERF SINGLE STUDY EACH 78491 "$3,869.00 " 404 "$2,708.30 " "$1,934.50 " "$3,095.20 " 65% of Billed Charges 80% of Billed Charges "$1,146.30 " "$1,146.30 " "$1,300.00 " Non Payable Non Payable 40400079 RADIOLOGY - PET PET RUBIDIUM RB-82 DX UP TO 60 EACH A9555 "$1,079.00 " 343 $755.30 $539.50 $863.20 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" $373.47 Non Payable Non Payable 40400087 RADIOLOGY - PET PET TUMOR IMAGING WHOLE BODY EACH 78813 "$3,869.00 " 404 "$2,708.30 " "$1,934.50 " "$3,095.20 " 65% of Billed Charges 80% of Billed Charges $829.87 $829.87 "$1,300.00 " Non Payable Non Payable 40400095 RADIOLOGY - PET PET TUMR IMAG SKULL MID-THIGH EACH 78812 "$3,869.00 " 404 "$2,708.30 " "$1,934.50 " "$3,095.20 " 65% of Billed Charges 80% of Billed Charges $829.87 $829.87 "$1,300.00 " Non Payable Non Payable 40400103 RADIOLOGY - PET PET TUMR IMG LTD CXR/HEAD/NECK EACH 78811 "$3,511.00 " 404 "$2,457.70 " "$1,755.50 " "$2,808.80 " 65% of Billed Charges 80% of Billed Charges $829.87 $829.87 "$1,300.00 " Non Payable Non Payable 40400129 RADIOLOGY - PET PET W/CT TUMR IMAG WHOLE BODY EACH 78816 "$3,869.00 " 404 "$2,708.30 " "$1,934.50 " "$3,095.20 " 65% of Billed Charges 80% of Billed Charges $829.87 $829.87 "$1,300.00 " Non Payable Non Payable 40400137 RADIOLOGY - PET PET W/CT TUMR LTD CXR/HEAD/NCK EACH 78814 "$3,869.00 " 404 "$2,708.30 " "$1,934.50 " "$3,095.20 " 65% of Billed Charges 80% of Billed Charges $829.87 $829.87 "$1,300.00 " Non Payable Non Payable 40400145 RADIOLOGY - PET PET W/CT TUMR SKULL MID-THIGH EACH 78815 "$3,869.00 " 404 "$2,708.30 " "$1,934.50 " "$3,095.20 " 65% of Billed Charges 80% of Billed Charges $829.87 $829.87 "$1,300.00 " Non Payable Non Payable 40200800 RADIOLOGY - US BIOPHYSICAL PROF (W NST) EACH 76818 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $111.50 Non Payable Non Payable 40200818 RADIOLOGY - US BIOPHYSICAL PROF (W/ NST) EACH 76819 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $82.12 Non Payable Non Payable 40200867 RADIOLOGY - US DOPPLER ECG FETAL EACH 76827 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $69.35 Non Payable Non Payable 40200875 RADIOLOGY - US DOPPLER ECG FETAL - REPEAT EACH 76828 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $49.35 Non Payable Non Payable 40200834 RADIOLOGY - US DOPPLER VELOCIMETRY - MCA EACH 76821 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $85.25 Non Payable Non Payable 40200826 RADIOLOGY - US DOPPLER VELOCIMETRY - UA EACH 76820 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $44.40 Non Payable Non Payable 40200842 RADIOLOGY - US "ECG, FETAL HEART " EACH 76825 "$1,365.00 " 402 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $476.83 $476.83 $257.62 Non Payable Non Payable 40200859 RADIOLOGY - US "ECG, FETAL HEART F/UP, REPEAT " EACH 76826 $606.00 402 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $360.78 $360.78 $153.43 Non Payable Non Payable 40200776 RADIOLOGY - US NUCHAL TRANLUCENCY ADD EACH 76814 $156.00 402 $109.20 $78.00 $124.80 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $74.24 Non Payable Non Payable 40200768 RADIOLOGY - US NUCHAL TRANLUCENCY SGL EACH 76813 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $114.65 Non Payable Non Payable 40200917 RADIOLOGY - US SALINE INFUSED SONOGRAM EACH 76831 $606.00 402 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $124.06 $124.06 $112.54 Non Payable Non Payable 40200784 RADIOLOGY - US US ABD F/UP - PER FETUS EACH 76816 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $106.74 Non Payable Non Payable 40200024 RADIOLOGY - US US ABDOMEN COMPLETE EACH 76700 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $116.68 Non Payable Non Payable 40200065 RADIOLOGY - US US CHEST EACH 76604 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $74.96 Non Payable Non Payable 40200099 RADIOLOGY - US US ENCEPHALOGRAM EACH 76506 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $109.51 Non Payable Non Payable 40200701 RADIOLOGY - US US EXTREMITY NONVASC COMPLETE EACH 76881 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.02 $77.02 $73.31 Non Payable Non Payable 40200719 RADIOLOGY - US US EXTREMITY NONVASC LTD EACH 76882 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.80 $49.80 $54.09 Non Payable Non Payable 40200891 RADIOLOGY - US US GUIDANCE FOR AMNIO (S & I) EACH 76946 $156.00 402 $109.20 $78.00 $124.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $30.55 Non Payable Non Payable 40200883 RADIOLOGY - US US GUIDANCE FOR CVS (S & I) EACH 76945 $156.00 402 $109.20 $78.00 $124.80 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $89.22 Non Payable Non Payable 40200321 RADIOLOGY - US US GUIDED ABSC DRAINAGE EACH 75989 $772.00 402 $540.40 $386.00 $617.60 65% of Billed Charges 80% of Billed Charges Non Payable Non Payable $130.12 Non Payable Non Payable 40200420 RADIOLOGY - US US HIPS INFANT DYNAMIC EACH 76885 $225.00 402 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $109.18 Non Payable Non Payable 40200438 RADIOLOGY - US US HIPS INFANT STATIC EACH 76886 $225.00 402 $157.50 $112.50 $180.00 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $99.62 Non Payable Non Payable 40200446 RADIOLOGY - US US KIDNEY TRANSPLANT W/DOPPLER EACH 76776 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $148.37 Non Payable Non Payable 40200750 RADIOLOGY - US US MATERNAL/DETAILED FETAL ADD EACH 76812 $156.00 402 $109.20 $78.00 $124.80 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $187.71 Non Payable Non Payable 40200743 RADIOLOGY - US US MATERNAL/DETAILED FETAL SGL EACH 76811 $606.00 402 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $124.06 $124.06 $167.57 Non Payable Non Payable 40200453 RADIOLOGY - US US PELVIS NON OB CMPL EACH 76856 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $103.56 Non Payable Non Payable 40200461 RADIOLOGY - US US PELVIS NON-OB LTD EACH 76857 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $46.07 Non Payable Non Payable 40200735 RADIOLOGY - US US PREGNANCY < 14 WKS ADD EACH 76802 $156.00 402 $109.20 $78.00 $124.80 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $59.43 Non Payable Non Payable 40200727 RADIOLOGY - US US PREGNANCY < 14 WKS SGL EACH 76801 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $115.84 Non Payable Non Payable 40200487 RADIOLOGY - US US PREGNANCY > OR =14 WKS ADD EACH 76810 $258.00 402 $180.60 $129.00 $206.40 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $87.15 Non Payable Non Payable 40200495 RADIOLOGY - US US PREGNANCY > OR =14 WKS SGL EACH 76805 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $132.52 Non Payable Non Payable 40200537 RADIOLOGY - US US PREGNANCY LTD EACH 76815 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $79.57 Non Payable Non Payable 40200560 RADIOLOGY - US US RETROPERITIONEAL COMPLETE EACH 76770 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $106.85 Non Payable Non Payable 40200578 RADIOLOGY - US US RETROPERITONEAL LTD EACH 76775 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $55.94 Non Payable Non Payable 40200941 RADIOLOGY - US US SCREEN ABD AORTIC ANEURYSM EACH 76706 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $90.15 $90.15 $107.70 Non Payable Non Payable 40200594 RADIOLOGY - US US SCROTUM EACH 76870 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $99.27 Non Payable Non Payable 40200602 RADIOLOGY - US US SOFT TISSUE HEAD/NECK EACH 76536 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $109.69 Non Payable Non Payable 40200628 RADIOLOGY - US US SPINAL CANAL EACH 76800 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $137.60 Non Payable Non Payable 40200636 RADIOLOGY - US US TRANSRECTAL EACH 76872 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $135.65 Non Payable Non Payable 40200644 RADIOLOGY - US US TRANSRECTAL PROSTATE VOLUME EACH 76873 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $165.69 Non Payable Non Payable 40200651 RADIOLOGY - US US TRANSVAGINAL NON OB EACH 76830 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $77.83 $77.83 $116.24 Non Payable Non Payable 40200792 RADIOLOGY - US US VAGINAL F/UP - PER FETUS EACH 76817 $272.00 402 $190.40 $136.00 $217.60 65% of Billed Charges 80% of Billed Charges $49.98 $49.98 $90.49 Non Payable Non Payable 62900360 RADIOLOYG - MRI MRI ABDOMEN W/CONTRAST EACH 74182 $951.00 614 $665.70 $475.50 $760.80 65% of Billed Charges 80% of Billed Charges $339.19 $339.19 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900568 RADIOLOYG - MRI MRI CARDIAC W/O CONT STRESS EACH 75559 "$1,365.00 " 614 $955.50 $682.50 "$1,092.00 " 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 62900915 RADIOLOYG - MRI MRI THORACIC SP W/O CONTRAST EACH 72146 $606.00 612 $424.20 $303.00 $484.80 65% of Billed Charges 80% of Billed Charges $279.62 $279.62 $515/Unit $750 each paid in addition to other neg. rates $750 each paid in addition to other neg. rates 71900104 RECOVERY ROOM PACU PHASE 1 EACH $800.00 710 $560.00 $400.00 $640.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 71900112 RECOVERY ROOM PACU PHASE 2 EACH $400.00 710 $280.00 $200.00 $320.00 65% of Billed Charges 80% of Billed Charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 21010012 ROOM AND BOARD CARDIAC CARE UNIT - JSH EACH "$5,906.00 " 210 "$4,134.20 " "$2,953.00 " "$4,724.80 " "$3,000.00 " "$3,000.00 " Non Payable Non Payable "$2,369 " "$2,300 " "$2,300 " 20710018 ROOM AND BOARD INTENSIVE CARE - BURN - JSH EACH "$5,906.00 " 207 "$4,134.20 " "$2,953.00 " "$4,724.80 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,300 " "$2,300 " 20210019 ROOM AND BOARD INTENSIVE CARE - MEDICAL - JSH EACH "$5,906.00 " 202 "$4,134.20 " "$2,953.00 " "$4,724.80 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,300 " "$2,300 " 20910014 ROOM AND BOARD INTENSIVE CARE - OTHER - JSH EACH "$5,906.00 " 209 "$4,134.20 " "$2,953.00 " "$4,724.80 " "$3,000.00 " "$3,000.00 " Non Payable Non Payable "$2,369 " "$2,300 " "$2,300 " 20310017 ROOM AND BOARD INTENSIVE CARE - PEDIATRIC-JSH EACH "$5,906.00 " 203 "$4,134.20 " "$2,953.00 " "$4,724.80 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,300 " "$2,300 " 20030011 ROOM AND BOARD INTENSIVE CARE - PHCC EACH "$5,906.00 " 200 "$4,134.20 " "$2,953.00 " "$4,724.80 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,300 " "$2,300 " 20110011 ROOM AND BOARD INTENSIVE CARE - SURGICAL -JSH EACH "$5,906.00 " 201 "$4,134.20 " "$2,953.00 " "$4,724.80 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,300 " "$2,300 " 20810016 ROOM AND BOARD INTENSIVE CARE - TRAUMA - JSH EACH "$5,906.00 " 208 "$4,134.20 " "$2,953.00 " "$4,724.80 " "$3,000.00 " "$3,000.00 " Non Payable Non Payable "$2,369 " "$2,300 " "$2,300 " 20612073 ROOM AND BOARD INTERMEDIATE ICU-JSH BURN EACH "$4,394.00 " 206 "$3,075.80 " "$2,197.00 " "$3,515.20 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,100 " "$2,100 " 20612107 ROOM AND BOARD INTERMEDIATE ICU-JSH CCU EACH "$4,394.00 " 206 "$3,075.80 " "$2,197.00 " "$3,515.20 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,100 " "$2,100 " 20612024 ROOM AND BOARD INTERMEDIATE ICU-JSH MEDICAL EACH "$4,394.00 " 206 "$3,075.80 " "$2,197.00 " "$3,515.20 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,100 " "$2,100 " 20612099 ROOM AND BOARD INTERMEDIATE ICU-JSH OTHER EACH "$4,394.00 " 206 "$3,075.80 " "$2,197.00 " "$3,515.20 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,100 " "$2,100 " 20612032 ROOM AND BOARD INTERMEDIATE ICU-JSH PEDIATRIC EACH "$4,394.00 " 206 "$3,075.80 " "$2,197.00 " "$3,515.20 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,100 " "$2,100 " 20612065 ROOM AND BOARD INTERMEDIATE ICU-JSH STEPDOWN EACH "$4,394.00 " 206 "$3,075.80 " "$2,197.00 " "$3,515.20 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,100 " "$2,100 " 20612016 ROOM AND BOARD INTERMEDIATE ICU-JSH SURGICAL EACH "$4,394.00 " 206 "$3,075.80 " "$2,197.00 " "$3,515.20 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,100 " "$2,100 " 20612081 ROOM AND BOARD INTERMEDIATE ICU-JSH TRAUMA EACH "$4,394.00 " 206 "$3,075.80 " "$2,197.00 " "$3,515.20 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,100 " "$2,100 " 20632006 ROOM AND BOARD INTERMEDIATE ICU-PHCC EACH "$4,394.00 " 206 "$3,075.80 " "$2,197.00 " "$3,515.20 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$2,369 " "$2,100 " "$2,100 " 17410010 ROOM AND BOARD NURSERY LEVEL FOUR - JSH EACH "$7,504.00 " 174 "$5,252.80 " "$3,752.00 " "$6,003.20 " "$3,000.00 " "$3,000.00 " Case Rates Only Case Rates Only "$2,369 " "$2,300 " "$2,300 " 17110016 ROOM AND BOARD NURSERY LEVEL ONE - JSH EACH "$2,583.00 " 171 "$1,808.10 " "$1,291.50 " "$2,066.40 " "$3,000.00 " "$3,000.00 " Case Rates Only Case Rates Only $515 $500 $500 17130014 ROOM AND BOARD NURSERY LEVEL ONE - PHCC EACH "$2,583.00 " 171 "$1,808.10 " "$1,291.50 " "$2,066.40 " "$3,000.00 " "$3,000.00 " Case Rates Only Case Rates Only $515 $500 $500 17310012 ROOM AND BOARD NURSERY LEVEL THREE - JSH EACH "$5,612.00 " 173 "$3,928.40 " "$2,806.00 " "$4,489.60 " "$3,000.00 " "$3,000.00 " Case Rates Only Case Rates Only "$1,545 " "$1,500 " "$1,500 " 17210014 ROOM AND BOARD NURSERY LEVEL TWO - JSH EACH "$3,750.00 " 172 "$2,625.00 " "$1,875.00 " "$3,000.00 " "$3,000.00 " "$3,000.00 " Case Rates Only Case Rates Only "$1,545 " "$1,200 " "$1,200 " 17230012 ROOM AND BOARD NURSERY LEVEL TWO - PHCC EACH "$3,750.00 " 172 "$2,625.00 " "$1,875.00 " "$3,000.00 " "$3,000.00 " "$3,000.00 " Case Rates Only Case Rates Only "$1,545 " "$1,200 " "$1,200 " 11110012 ROOM AND BOARD PVT MED/SURG - JSH EACH "$3,177.00 " 111 "$2,223.90 " "$1,588.50 " "$2,541.60 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 11130010 ROOM AND BOARD PVT MED/SURG - PHCC EACH "$3,177.00 " 111 "$2,223.90 " "$1,588.50 " "$2,541.60 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 11210010 ROOM AND BOARD PVT OB - JSH EACH "$3,177.00 " 112 "$2,223.90 " "$1,588.50 " "$2,541.60 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 11230018 ROOM AND BOARD PVT OB- PHCC EACH "$3,177.00 " 112 "$2,223.90 " "$1,588.50 " "$2,541.60 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 11310018 ROOM AND BOARD PVT PEDS - JSH EACH "$3,177.00 " 113 "$2,223.90 " "$1,588.50 " "$2,541.60 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 12110011 ROOM AND BOARD SEMI-PVT - MED/SURG/GYN - JSH EACH "$3,158.00 " 121 "$2,210.60 " "$1,579.00 " "$2,526.40 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 12130019 ROOM AND BOARD SEMI-PVT - MED/SURG/GYN - PHCC EACH "$3,158.00 " 121 "$2,210.60 " "$1,579.00 " "$2,526.40 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 12210019 ROOM AND BOARD SEMI-PVT - OB - JSH EACH "$3,158.00 " 122 "$2,210.60 " "$1,579.00 " "$2,526.40 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 12230017 ROOM AND BOARD SEMI-PVT - OB - PHCC EACH "$3,158.00 " 122 "$2,210.60 " "$1,579.00 " "$2,526.40 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 12310017 ROOM AND BOARD SEMI-PVT - PEDS - JSH EACH "$3,158.00 " 123 "$2,210.60 " "$1,579.00 " "$2,526.40 " "$3,000.00 " "$3,000.00 " "$1,870 " "$1,700 " "$1,545 " "$1,500 " "$1,500 " 92799964 SLEEP LAB HOME SLEEP STUDY PORT MONITOR EACH G0400 $777.00 920 $543.90 $388.50 $621.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92700004 SLEEP LAB MULT SLEEP/WAKE LATENCY (MSLT) EACH 95805 "$1,326.00 " 920 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92700012 SLEEP LAB PSG 1-3 PARAMETERS EACH 95808 "$2,586.00 " 920 "$1,810.20 " "$1,293.00 " "$2,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92700079 SLEEP LAB PSG 4 OR > PARAMETERS W/SPLIT EACH 95811 "$2,586.00 " 920 "$1,810.20 " "$1,293.00 " "$2,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92700020 SLEEP LAB PSG 4 OR MORE PARAMETERS (PSG) EACH 95810 "$2,586.00 " 920 "$1,810.20 " "$1,293.00 " "$2,068.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92700129 SLEEP LAB SLEEP STUDY ATTENDED EACH 95807 "$1,326.00 " 920 $928.20 $663.00 "$1,060.80 " Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92700103 SLEEP LAB SLEEP STUDY UNATND W/RESP ANAL EACH 95801 $152.00 920 $106.40 $76.00 $121.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92700095 SLEEP LAB SLEEP STUDY UNATTENDED EACH 95800 $387.00 920 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 92700053 SLEEP LAB SLEEP STUDY UNATTENDED W/RESP EACH 95806 $387.00 920 $270.90 $193.50 $309.60 Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable Non Payable 44000313 SPEECH THERAPY ANALYSIS OF VOICE/RESONANCE EACH 92524 $127.00 444 $88.90 $63.50 $101.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000271 SPEECH THERAPY EVAL OF SPEECH FLUENCY EACH 92521 $143.00 444 $100.10 $71.50 $114.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000297 SPEECH THERAPY EVAL SOUND PRODUCTION W/COMPR EACH 92523 $246.00 444 $172.20 $123.00 $196.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000289 SPEECH THERAPY EVAL SPEECH SOUND PRODUCTION EACH 92522 $127.00 444 $88.90 $63.50 $101.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000016 SPEECH THERAPY ST EVAL APHASIA PER HR EACH 96105 $234.00 444 $163.80 $117.00 $187.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000024 SPEECH THERAPY ST EVAL LARYNX ENDO C/V EACH 92614 $190.00 444 $133.00 $95.00 $152.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000040 SPEECH THERAPY ST EVAL ORAL/SWALLOW FUNCTION EACH 92610 $238.00 444 $166.60 $119.00 $190.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000057 SPEECH THERAPY ST EVAL SPEECH DEVICE 1ST HR EACH 92607 $451.00 444 $315.70 $225.50 $360.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000065 SPEECH THERAPY ST EVAL SPEECH DEVICE ADD 30M EACH 92608 $91.00 444 $63.70 $45.50 $72.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000081 SPEECH THERAPY ST EVAL SWALL ENDO C/V EACH 92612 $190.00 444 $133.00 $95.00 $152.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000099 SPEECH THERAPY ST EVAL SWALL/LARYNX C/V EACH 92616 $281.00 444 $196.70 $140.50 $224.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000107 SPEECH THERAPY ST EVAL SWALLVIDEO/FLUORO EACH 92611 $259.00 444 $181.30 $129.50 $207.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000115 SPEECH THERAPY ST EVAL VOICE PROSTHETIC EACH 92597 $130.00 440 $91.00 $65.00 $104.00 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000032 SPEECH THERAPY ST EXAM NONSPEECH DEVICE RX EACH 92605 $239.00 444 $167.30 $119.50 $191.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000123 SPEECH THERAPY ST FACIAL NERVE FUNC STUDY EACH 92516 $777.00 440 $543.90 $388.50 $621.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000131 SPEECH THERAPY ST LARYNGEAL FUNCTION STUDY EACH 92520 $316.00 440 $221.20 $158.00 $252.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000149 SPEECH THERAPY ST MODIFY/TRAIN VOICE PROSTH EACH 92609 $241.00 440 $168.70 $120.50 $192.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000230 SPEECH THERAPY ST TREAT NON-SPEECH DEVICE EACH 92606 $168.00 440 $117.60 $84.00 $134.40 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000248 SPEECH THERAPY ST TREAT SPEECH EACH 92507 $82.00 440 $57.40 $41.00 $65.60 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000255 SPEECH THERAPY ST TREAT SPEECH GROUP EACH 92508 $39.00 443 $27.30 $19.50 $31.20 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 44000263 SPEECH THERAPY ST TX SWALLOW/ORAL EACH 92526 $91.00 440 $63.70 $45.50 $72.80 65% of Billed Charges 80% of Billed Charges $110/visit $100/visit 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27003151 SUPPLIES ACUSNARE POLYPECTOMY EACH $36.00 272 $25.20 $18.00 $28.80 65% 80% 50% 50% 65% 65% 65% 27028992 SUPPLIES AFO ANKLE GAUNTLET LVL 0 EACH L1902 $75.00 274 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029057 SUPPLIES AFO ANKLE GAUNTLET LVL 1 EACH L1902 $150.00 274 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029065 SUPPLIES AFO ANKLE GAUNTLET LVL 2 EACH L1902 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029123 SUPPLIES AFO ANKLE GAUNTLET LVL 3 EACH L1902 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029131 SUPPLIES AFO ANKLE GAUNTLET LVL 4 EACH L1902 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029198 SUPPLIES AFO ANKLE GAUNTLET LVL 5 EACH L1902 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27002591 SUPPLIES AFO PLASTIC PREFABRICATED EACH L1930 $0.00 274 $0.00 $0.00 $0.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27026533 SUPPLIES AMNIOTIC MEMBRANE LVL 0 EACH V2790 $75.00 810 $52.50 $37.50 $60.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026541 SUPPLIES AMNIOTIC MEMBRANE LVL 1 EACH V2790 $150.00 810 $105.00 $75.00 $120.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026889 SUPPLIES AMNIOTIC MEMBRANE LVL 10 EACH V2790 "$26,000.00 " 810 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026608 SUPPLIES AMNIOTIC MEMBRANE LVL 2 EACH V2790 $300.00 810 $210.00 $150.00 $240.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026616 SUPPLIES AMNIOTIC MEMBRANE LVL 3 EACH V2790 $600.00 810 $420.00 $300.00 $480.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026673 SUPPLIES AMNIOTIC MEMBRANE LVL 4 EACH V2790 "$1,200.00 " 810 $840.00 $600.00 $960.00 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026681 SUPPLIES AMNIOTIC MEMBRANE LVL 5 EACH V2790 "$2,400.00 " 810 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026749 SUPPLIES AMNIOTIC MEMBRANE LVL 6 EACH V2790 "$5,000.00 " 810 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026756 SUPPLIES AMNIOTIC MEMBRANE LVL 7 EACH V2790 "$9,400.00 " 810 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026814 SUPPLIES AMNIOTIC MEMBRANE LVL 8 EACH V2790 "$15,000.00 " 810 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27026822 SUPPLIES AMNIOTIC MEMBRANE LVL 9 EACH V2790 "$20,000.00 " 810 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% of billed charges 80% of billed charges 50% of Billed Charges 50% of Billed Charges 65% of Billed Charges 65% of Billed Charges 65% of Billed Charges 27030253 SUPPLIES ANKLE CONTROL ORTH PREFAB L0 EACH L4350 $98.00 274 $68.60 $49.00 $78.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030311 SUPPLIES ANKLE CONTROL ORTH PREFAB L1 EACH L4350 $150.00 274 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030329 SUPPLIES ANKLE CONTROL ORTH PREFAB L2 EACH L4350 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030386 SUPPLIES ANKLE CONTROL ORTH PREFAB L3 EACH L4350 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030394 SUPPLIES ANKLE CONTROL ORTH PREFAB L4 EACH L4350 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030451 SUPPLIES ANKLE CONTROL ORTH PREFAB L5 EACH L4350 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27005255 SUPPLIES AUXILLARY CHANNEL WATER TUBE EACH $93.00 272 $65.10 $46.50 $74.40 65% 80% 50% 50% 65% 65% 65% 27000199 SUPPLIES BARR SKIN EXT WEAR <= 4 SQ/EA EACH $10.50 272 $7.35 $5.25 $8.40 65% 80% 50% 50% 65% 65% 65% 27003573 SUPPLIES BASIC EYE PACK-LF EACH $237.00 272 $165.90 $118.50 $189.60 65% 80% 50% 50% 65% 65% 65% 27006303 SUPPLIES BLADE LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27006378 SUPPLIES BLADE LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27007004 SUPPLIES BLADE LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27006444 SUPPLIES BLADE LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27006584 SUPPLIES BLADE LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27006659 SUPPLIES BLADE LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27006725 SUPPLIES BLADE LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27006790 SUPPLIES BLADE LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27006865 SUPPLIES BLADE LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27006931 SUPPLIES BLADE LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27012400 SUPPLIES BREAST MILK PROC/STORE/DIST EACH T2101 $11.00 220 $7.70 $5.50 $8.80 65% 80% 50% 50% 65% 65% 65% 27003649 SUPPLIES BURN PACK-LF EACH $582.00 272 $407.40 $291.00 $465.60 65% 80% 50% 50% 65% 65% 65% 27007079 SUPPLIES BURR HOLE COVER LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27007145 SUPPLIES BURR HOLE COVER LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27007772 SUPPLIES BURR HOLE COVER LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27007210 SUPPLIES BURR HOLE COVER LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27007285 SUPPLIES BURR HOLE COVER LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27007350 SUPPLIES BURR HOLE COVER LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27007426 SUPPLIES BURR HOLE COVER LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27007491 SUPPLIES BURR HOLE COVER LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27007566 SUPPLIES BURR HOLE COVER LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27007632 SUPPLIES BURR HOLE COVER LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27007707 SUPPLIES BURR HOLE COVER LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27007848 SUPPLIES CABLE LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27007913 SUPPLIES CABLE LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27008549 SUPPLIES CABLE LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27007988 SUPPLIES CABLE LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27008051 SUPPLIES CABLE LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27008127 SUPPLIES CABLE LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27008192 SUPPLIES CABLE LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27008267 SUPPLIES CABLE LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27008333 SUPPLIES CABLE LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27008408 SUPPLIES CABLE LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27008473 SUPPLIES CABLE LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27002872 SUPPLIES CAPTURA BIOPSY FORCEP EACH $30.00 272 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 27005677 SUPPLIES "CARDIO -CATHETERS, ASPIRATION " EACH "$1,350.00 " 272 $945.00 $675.00 "$1,080.00 " 65% 80% 50% 50% 65% 65% 65% 27005537 SUPPLIES CARDIO-CONTROL WIRE CATHETERS EACH "$1,950.00 " 272 "$1,365.00 " $975.00 "$1,560.00 " 65% 80% 50% 50% 65% 65% 65% 27005883 SUPPLIES CARDIOLGY-INFLATOR DEVICE KIT EACH $99.00 272 $69.30 $49.50 $79.20 65% 80% 50% 50% 65% 65% 65% 27005461 SUPPLIES CARDIOLOGY - ARGON NEEDLES EACH $3.00 272 $2.10 $1.50 $2.40 65% 80% 50% 50% 65% 65% 65% 27005602 SUPPLIES CARDIOLOGY - DX CATHETERS EACH $24.00 272 $16.80 $12.00 $19.20 65% 80% 50% 50% 65% 65% 65% 27005743 SUPPLIES CARDIOLOGY - FFR WIRES EACH $18.00 272 $12.60 $9.00 $14.40 65% 80% 50% 50% 65% 65% 65% 27005818 SUPPLIES CARDIOLOGY - IABP CATHETERS EACH "$2,888.00 " 272 "$2,021.60 " "$1,444.00 " "$2,310.40 " 65% 80% 50% 50% 65% 65% 65% 27005958 SUPPLIES CARDIOLOGY - MANIFOLD KITS EACH $78.00 272 $54.60 $39.00 $62.40 65% 80% 50% 50% 65% 65% 65% 27006238 SUPPLIES CARDIOLOGY - RADIAL PRODUCTS EACH $599.00 272 $419.30 $299.50 $479.20 65% 80% 50% 50% 65% 65% 65% 27006162 SUPPLIES CARDIOLOGY - SNAP KOVER EACH $117.00 272 $81.90 $58.50 $93.60 65% 80% 50% 50% 65% 65% 65% 27006022 SUPPLIES CARDIOLOGY-PACEMAKER PRODUCTS EACH $30.00 272 $21.00 $15.00 $24.00 65% 80% 50% 50% 65% 65% 65% 27006097 SUPPLIES CARDIOLOGY-PERICARDIOCENTESIS EACH $50.00 272 $35.00 $25.00 $40.00 65% 80% 50% 50% 65% 65% 65% 27026111 SUPPLIES CAST SUPPLIES UNLISTED LVL 0 EACH Q4050 $75.00 270 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27026129 SUPPLIES CAST SUPPLIES UNLISTED LVL 1 EACH Q4050 $150.00 270 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27026186 SUPPLIES CAST SUPPLIES UNLISTED LVL 2 EACH Q4050 $300.00 270 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27026194 SUPPLIES CAST SUPPLIES UNLISTED LVL 3 EACH Q4050 $600.00 270 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27026251 SUPPLIES CAST SUPPLIES UNLISTED LVL 4 EACH Q4050 "$1,200.00 " 270 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27026269 SUPPLIES CAST SUPPLIES UNLISTED LVL 5 EACH Q4050 "$2,400.00 " 270 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27003714 SUPPLIES CATH LAB PACK EACH $103.00 272 $72.10 $51.50 $82.40 65% 80% 50% 50% 65% 65% 65% 27031723 SUPPLIES CATHETER URETERAL LVL 0 EACH C1758 $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27031780 SUPPLIES CATHETER URETERAL LVL 1 EACH C1758 $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27031798 SUPPLIES CATHETER URETERAL LVL 2 EACH C1758 $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27031855 SUPPLIES CATHETER URETERAL LVL 3 EACH C1758 $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27031863 SUPPLIES CATHETER URETERAL LVL 4 EACH C1758 "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27031921 SUPPLIES CATHETER URETERAL LVL 5 EACH C1758 "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27024785 SUPPLIES CATHETER LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27024850 SUPPLIES CATHETER LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27025485 SUPPLIES CATHETER LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27024926 SUPPLIES CATHETER LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27024991 SUPPLIES CATHETER LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27025063 SUPPLIES CATHETER LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27025139 SUPPLIES CATHETER LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27025204 SUPPLIES CATHETER LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27025279 SUPPLIES CATHETER LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27025345 SUPPLIES CATHETER LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27025410 SUPPLIES CATHETER LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27032770 SUPPLIES CERV COLLAR SEMI-RIGID LVL 0 EACH L0172 $143.00 274 $100.10 $71.50 $114.40 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032838 SUPPLIES CERV COLLAR SEMI-RIGID LVL 1 EACH L0172 $150.00 274 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032846 SUPPLIES CERV COLLAR SEMI-RIGID LVL 2 EACH L0172 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032903 SUPPLIES CERV COLLAR SEMI-RIGID LVL 3 EACH L0172 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032911 SUPPLIES CERV COLLAR SEMI-RIGID LVL 4 EACH L0172 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032978 SUPPLIES CERV COLLAR SEMI-RIGID LVL 5 EACH L0172 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028364 SUPPLIES CERV FLEX NON-ADJUSTABLE L0 EACH L0120 $75.00 274 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028422 SUPPLIES CERV FLEX NON-ADJUSTABLE L1 EACH L0120 $150.00 274 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028430 SUPPLIES CERV FLEX NON-ADJUSTABLE L2 EACH L0120 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028497 SUPPLIES CERV FLEX NON-ADJUSTABLE L3 EACH L0120 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028505 SUPPLIES CERV FLEX NON-ADJUSTABLE L4 EACH L0120 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028562 SUPPLIES CERV FLEX NON-ADJUSTABLE L5 EACH L0120 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27003367 SUPPLIES CHANNEL CLEANING BRUSH EACH $7.00 272 $4.90 $3.50 $5.60 65% 80% 50% 50% 65% 65% 65% 27009380 SUPPLIES CLAMP LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27009455 SUPPLIES CLAMP LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27010081 SUPPLIES CLAMP LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27009521 SUPPLIES CLAMP LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27009596 SUPPLIES CLAMP LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27009661 SUPPLIES CLAMP LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27009737 SUPPLIES CLAMP LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27009802 SUPPLIES CLAMP LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27009877 SUPPLIES CLAMP LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27009943 SUPPLIES CLAMP LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27010016 SUPPLIES CLAMP LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27010156 SUPPLIES CLIP APPLIER LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27010222 SUPPLIES CLIP APPLIER LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27010859 SUPPLIES CLIP APPLIER LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27010297 SUPPLIES CLIP APPLIER LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27010362 SUPPLIES CLIP APPLIER LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27010438 SUPPLIES CLIP APPLIER LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27010503 SUPPLIES CLIP APPLIER LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27010578 SUPPLIES CLIP APPLIER LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27010644 SUPPLIES CLIP APPLIER LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27010719 SUPPLIES CLIP APPLIER LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27010784 SUPPLIES CLIP APPLIER LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27010925 SUPPLIES CLIP LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27010990 SUPPLIES CLIP LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27011626 SUPPLIES CLIP LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27011063 SUPPLIES CLIP LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27011139 SUPPLIES CLIP LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27011204 SUPPLIES CLIP LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27011279 SUPPLIES CLIP LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27011345 SUPPLIES CLIP LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27011410 SUPPLIES CLIP LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27011485 SUPPLIES CLIP LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27011550 SUPPLIES CLIP LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27033059 SUPPLIES CMF IMPLANT KIT XLG 54440400 EACH "$24,408.00 " 272 "$17,085.60 " "$12,204.00 " "$19,526.40 " 65% 80% 50% 50% 65% 65% 65% 27002609 SUPPLIES COLLAR CERV SEMI-RIGID ADJ EACH L0140 $0.00 274 $0.00 $0.00 $0.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27002617 SUPPLIES COLLAR CERV SEMI-RIGID W/CHIN EACH L0150 $0.00 274 $0.00 $0.00 $0.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27002815 SUPPLIES CUSTOM PACK - BASIC EACH $92.00 272 $64.40 $46.00 $73.60 65% 80% 50% 50% 65% 65% 65% 27002823 SUPPLIES CUSTOM PACK - CRANIOTOMY EACH $237.00 272 $165.90 $118.50 $189.60 65% 80% 50% 50% 65% 65% 65% 27002831 SUPPLIES CUSTOM PACK - OPEN HEART EACH $725.00 272 $507.50 $362.50 $580.00 65% 80% 50% 50% 65% 65% 65% 27002807 SUPPLIES CUSTOM PACK CATARACT EACH $133.00 272 $93.10 $66.50 $106.40 65% 80% 50% 50% 65% 65% 65% 27031301 SUPPLIES CYMETRA INJECTABLE 1 CC EACH Q4112 $987.00 636 $690.90 $493.50 $789.60 65% of Billed Charges 80% of Billed Charges "> $2500 50% charges NTE $10,000" "> $2500 50% charges NTE $10,000" 42% billed charges + applicable per diems Cost +15% [$1000 threshold per RC] - equates to 67% discount Cost +15% [$1000 threshold per RC] - equates to 67% discount 27003789 SUPPLIES CYSTO PACK-LF EACH $45.00 272 $31.50 $22.50 $36.00 65% 80% 50% 50% 65% 65% 65% 27003086 SUPPLIES DISPOSABLE VARICES INJECTOR EACH $128.00 272 $89.60 $64.00 $102.40 65% 80% 50% 50% 65% 65% 65% 27000967 SUPPLIES DSG ALGINATE 16 OR LESS EA EACH $0.00 272 $0.00 $0.00 $0.00 65% 80% 50% 50% 65% 65% 65% 27027523 SUPPLIES ENTERAL NG TUBE W/O STYLET L0 EACH B4082 $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27027580 SUPPLIES ENTERAL NG TUBE W/O STYLET L1 EACH B4082 $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27027598 SUPPLIES ENTERAL NG TUBE W/O STYLET L2 EACH B4082 $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27027655 SUPPLIES ENTERAL NG TUBE W/O STYLET L3 EACH B4082 $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27027663 SUPPLIES ENTERAL NG TUBE W/O STYLET L4 EACH B4082 "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27027721 SUPPLIES ENTERAL NG TUBE W/O STYLET L5 EACH B4082 "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27027317 SUPPLIES ENTERAL NG TUBE W/STYLET LVL 0 EACH B4081 $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27027374 SUPPLIES ENTERAL NG TUBE W/STYLET LVL 1 EACH B4081 $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27027382 SUPPLIES ENTERAL NG TUBE W/STYLET LVL 2 EACH B4081 $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27027440 SUPPLIES ENTERAL NG TUBE W/STYLET LVL 3 EACH B4081 $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27027457 SUPPLIES ENTERAL NG TUBE W/STYLET LVL 4 EACH B4081 "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27027515 SUPPLIES ENTERAL NG TUBE W/STYLET LVL 5 EACH B4081 "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27027739 SUPPLIES ENTERAL STOMACH TUBE LEV L0 EACH B4083 $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27027796 SUPPLIES ENTERAL STOMACH TUBE LEV L1 EACH B4083 $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27027804 SUPPLIES ENTERAL STOMACH TUBE LEV L2 EACH B4083 $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27027861 SUPPLIES ENTERAL STOMACH TUBE LEV L3 EACH B4083 $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27027879 SUPPLIES ENTERAL STOMACH TUBE LEV L4 EACH B4083 "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27027937 SUPPLIES ENTERAL STOMACH TUBE LEV L5 EACH B4083 "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27002625 SUPPLIES EO RIGID W/O JOINTS PREFAB EACH L3762 $0.00 274 $0.00 $0.00 $0.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27011691 SUPPLIES EXTERNAL FIXATOR LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27011766 SUPPLIES EXTERNAL FIXATOR LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27012392 SUPPLIES EXTERNAL FIXATOR LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27011832 SUPPLIES EXTERNAL FIXATOR LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27011907 SUPPLIES EXTERNAL FIXATOR LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27011972 SUPPLIES EXTERNAL FIXATOR LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27012046 SUPPLIES EXTERNAL FIXATOR LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27012111 SUPPLIES EXTERNAL FIXATOR LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27012186 SUPPLIES EXTERNAL FIXATOR LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27012251 SUPPLIES EXTERNAL FIXATOR LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27012327 SUPPLIES EXTERNAL FIXATOR LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27003508 SUPPLIES FILTER FOR OFP EACH $20.00 272 $14.00 $10.00 $16.00 65% 80% 50% 50% 65% 65% 65% 27025915 SUPPLIES FINGER SPLINT STATIC LVL 1 EACH Q4049 $150.00 270 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27025972 SUPPLIES FINGER SPLINT STATIC LVL 2 EACH Q4049 $300.00 270 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27025980 SUPPLIES FINGER SPLINT STATIC LVL 3 EACH Q4049 $600.00 270 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27026046 SUPPLIES FINGER SPLINT STATIC LVL 4 EACH Q4049 "$1,200.00 " 270 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27026053 SUPPLIES FINGER SPLINT STATIC LVL 5 EACH Q4049 "$2,400.00 " 270 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27025907 SUPPLIES "FINGER SPLINT, STATIC LVL 0 " EACH Q4049 $75.00 270 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27028158 SUPPLIES GASTRO TUBE LOW-PRO LVL 0 EACH B4088 $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27028216 SUPPLIES GASTRO TUBE LOW-PRO LVL 1 EACH B4088 $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27028224 SUPPLIES GASTRO TUBE LOW-PRO LVL 2 EACH B4088 $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27028281 SUPPLIES GASTRO TUBE LOW-PRO LVL 3 EACH B4088 $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27028299 SUPPLIES GASTRO TUBE LOW-PRO LVL 4 EACH B4088 "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27028356 SUPPLIES GASTRO TUBE LOW-PRO LVL 5 EACH B4088 "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27027945 SUPPLIES GASTRO/JEJUNO TUBE STD LVL 0 EACH B4087 $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27028000 SUPPLIES GASTRO/JEJUNO TUBE STD LVL 1 EACH B4087 $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27028018 SUPPLIES GASTRO/JEJUNO TUBE STD LVL 2 EACH B4087 $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27028075 SUPPLIES GASTRO/JEJUNO TUBE STD LVL 3 EACH B4087 $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27028083 SUPPLIES GASTRO/JEJUNO TUBE STD LVL 4 EACH B4087 "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27028141 SUPPLIES GASTRO/JEJUNO TUBE STD LVL 5 EACH B4087 "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27027101 SUPPLIES GAUZE >16<=48 NO W/SAL LVL 0 EACH A6223 $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27027168 SUPPLIES GAUZE >16<=48 NO W/SAL LVL 1 EACH A6223 $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27027176 SUPPLIES GAUZE >16<=48 NO W/SAL LVL 2 EACH A6223 $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27027234 SUPPLIES GAUZE >16<=48 NO W/SAL LVL 3 EACH A6223 $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27027242 SUPPLIES GAUZE >16<=48 NO W/SAL LVL 4 EACH A6223 "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27027309 SUPPLIES GAUZE >16<=48 NO W/SAL LVL 5 EACH A6223 "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27003854 SUPPLIES GENERAL LAP PACK-LF EACH $181.00 272 $126.70 $90.50 $144.80 65% 80% 50% 50% 65% 65% 65% 27003920 SUPPLIES GENERAL MINOR PACK-LF EACH $148.00 272 $103.60 $74.00 $118.40 65% 80% 50% 50% 65% 65% 65% 27033257 SUPPLIES GRAFT EPRSTH 10CM 21MM 21MM EACH "$24,375.00 " 270 "$17,062.50 " "$12,187.50 " "$19,500.00 " 65% 80% 50% 50% 65% 65% 65% 27033190 SUPPLIES GRAFT EPRSTH 10CM 26MM 26MM EACH "$24,375.00 " 270 "$17,062.50 " "$12,187.50 " "$19,500.00 " 65% 80% 50% 50% 65% 65% 65% 27032986 SUPPLIES GRAFT SRG 13.8X7.5IN 1161935 EACH "$26,933.00 " 272 "$18,853.10 " "$13,466.50 " "$21,546.40 " 65% 80% 50% 50% 65% 65% 65% 27003227 SUPPLIES GUARDUS OVERTUBES EACH $468.00 272 $327.60 $234.00 $374.40 65% 80% 50% 50% 65% 65% 65% 27003995 SUPPLIES GYN MINOR PACK EACH $110.00 272 $77.00 $55.00 $88.00 65% 80% 50% 50% 65% 65% 65% 27004068 SUPPLIES HAND PACK EACH $174.00 272 $121.80 $87.00 $139.20 65% 80% 50% 50% 65% 65% 65% 27004134 SUPPLIES HEAD & NECK PACK-LF EACH $153.00 272 $107.10 $76.50 $122.40 65% 80% 50% 50% 65% 65% 65% 27013234 SUPPLIES HEMOSTATIC/SEALANT LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27013309 SUPPLIES HEMOSTATIC/SEALANT LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27013937 SUPPLIES HEMOSTATIC/SEALANT LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27013374 SUPPLIES HEMOSTATIC/SEALANT LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27013440 SUPPLIES HEMOSTATIC/SEALANT LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27013515 SUPPLIES HEMOSTATIC/SEALANT LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27013580 SUPPLIES HEMOSTATIC/SEALANT LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27013655 SUPPLIES HEMOSTATIC/SEALANT LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27013721 SUPPLIES HEMOSTATIC/SEALANT LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27013796 SUPPLIES HEMOSTATIC/SEALANT LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27013861 SUPPLIES HEMOSTATIC/SEALANT LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27004209 SUPPLIES HIP PACK-LF EACH $319.00 272 $223.30 $159.50 $255.20 65% 80% 50% 50% 65% 65% 65% 27026897 SUPPLIES INFUSION PUMP REFILL KIT LVL 0 EACH A4220 $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27026954 SUPPLIES INFUSION PUMP REFILL KIT LVL 1 EACH A4220 $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27026962 SUPPLIES INFUSION PUMP REFILL KIT LVL 2 EACH A4220 $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27027028 SUPPLIES INFUSION PUMP REFILL KIT LVL 3 EACH A4220 $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27027036 SUPPLIES INFUSION PUMP REFILL KIT LVL 4 EACH A4220 "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27024017 SUPPLIES INTRODUCER LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27024082 SUPPLIES INTRODUCER LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27024710 SUPPLIES INTRODUCER LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27024157 SUPPLIES INTRODUCER LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27024223 SUPPLIES INTRODUCER LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27024298 SUPPLIES INTRODUCER LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27024363 SUPPLIES INTRODUCER LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27024439 SUPPLIES INTRODUCER LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27024504 SUPPLIES INTRODUCER LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27024579 SUPPLIES INTRODUCER LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27024645 SUPPLIES INTRODUCER LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27003433 SUPPLIES IRRIGATION FOR OFP EACH $31.00 272 $21.70 $15.50 $24.80 65% 80% 50% 50% 65% 65% 65% 27004977 SUPPLIES "KIT,N-S,BRONCHIAL,COOK COUNTY " EACH $41.00 272 $28.70 $20.50 $32.80 65% 80% 50% 50% 65% 65% 65% 27005040 SUPPLIES "KIT,N-S,EGD,COOK COUNTY HOSP " EACH $31.00 272 $21.70 $15.50 $24.80 65% 80% 50% 50% 65% 65% 65% 27005115 SUPPLIES "KIT,N-S,ENDO,COOK COUNTY HOSP " EACH $26.00 272 $18.20 $13.00 $20.80 65% 80% 50% 50% 65% 65% 65% 27032358 SUPPLIES KNEE ORTHOTIC ADJUSTABLE LV 0 EACH L1832 $692.00 274 $484.40 $346.00 $553.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032416 SUPPLIES KNEE ORTHOTIC ADJUSTABLE LV 1 EACH L1832 $692.00 274 $484.40 $346.00 $553.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032424 SUPPLIES KNEE ORTHOTIC ADJUSTABLE LV 2 EACH L1832 $692.00 274 $484.40 $346.00 $553.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032481 SUPPLIES KNEE ORTHOTIC ADJUSTABLE LV 3 EACH L1832 $692.00 274 $484.40 $346.00 $553.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032499 SUPPLIES KNEE ORTHOTIC ADJUSTABLE LV 4 EACH L1832 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032556 SUPPLIES KNEE ORTHOTIC ADJUSTABLE LV 5 EACH L1832 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032564 SUPPLIES KNEE ORTHOTIC IMMOB LVL 0 EACH L1830 $75.00 274 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032622 SUPPLIES KNEE ORTHOTIC IMMOB LVL 1 EACH L1830 $150.00 274 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032630 SUPPLIES KNEE ORTHOTIC IMMOB LVL 2 EACH L1830 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032697 SUPPLIES KNEE ORTHOTIC IMMOB LVL 3 EACH L1830 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032705 SUPPLIES KNEE ORTHOTIC IMMOB LVL 4 EACH L1830 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032762 SUPPLIES KNEE ORTHOTIC IMMOB LVL 5 EACH L1830 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028844 SUPPLIES KO SINGLE UPRIGHT CUSTOM L 1 EACH L1843 $901.00 274 $630.70 $450.50 $720.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028786 SUPPLIES KO SINGLE UPRIGHT CUSTOM L0 EACH L1843 $901.00 274 $630.70 $450.50 $720.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028851 SUPPLIES KO SINGLE UPRIGHT CUSTOM L2 EACH L1843 $901.00 274 $630.70 $450.50 $720.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028919 SUPPLIES KO SINGLE UPRIGHT CUSTOM L3 EACH L1843 $901.00 274 $630.70 $450.50 $720.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028927 SUPPLIES KO SINGLE UPRIGHT CUSTOM L4 EACH L1843 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028984 SUPPLIES KO SINGLE UPRIGHT CUSTOM L5 EACH L1843 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27014000 SUPPLIES KWIRE LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27014075 SUPPLIES KWIRE LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27014703 SUPPLIES KWIRE LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27014141 SUPPLIES KWIRE LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27014216 SUPPLIES KWIRE LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27014281 SUPPLIES KWIRE LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27014356 SUPPLIES KWIRE LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27014422 SUPPLIES KWIRE LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27014497 SUPPLIES KWIRE LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27014562 SUPPLIES KWIRE LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27014638 SUPPLIES KWIRE LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27028570 SUPPLIES LO FLEX WO RIGID STAYS PRE L 0 EACH L0628 $75.00 274 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028638 SUPPLIES LO FLEX WO RIGID STAYS PRE L1 EACH L0628 $150.00 274 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028646 SUPPLIES LO FLEX WO RIGID STAYS PRE L2 EACH L0628 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028703 SUPPLIES LO FLEX WO RIGID STAYS PRE L3 EACH L0628 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028711 SUPPLIES LO FLEX WO RIGID STAYS PRE L4 EACH L0628 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27028778 SUPPLIES LO FLEX WO RIGID STAYS PRE L5 EACH L0628 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27004274 SUPPLIES LOWER EXTREMITY PACK-LF EACH $233.00 272 $163.10 $116.50 $186.40 65% 80% 50% 50% 65% 65% 65% 27004340 SUPPLIES MAJOR ABDOMINAL-LF EACH $215.00 272 $150.50 $107.50 $172.00 65% 80% 50% 50% 65% 65% 65% 27004415 SUPPLIES MAJOR CRANIOTOMY PACK-LF EACH $998.00 272 $698.60 $499.00 $798.40 65% 80% 50% 50% 65% 65% 65% 27031095 SUPPLIES METACARPOPHAL IMPLANT LVL 0 EACH L8630 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031152 SUPPLIES METACARPOPHAL IMPLANT LVL 1 EACH L8630 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031160 SUPPLIES METACARPOPHAL IMPLANT LVL 2 EACH L8630 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031228 SUPPLIES METACARPOPHAL IMPLANT LVL 3 EACH L8630 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031236 SUPPLIES METACARPOPHAL IMPLANT LVL 4 EACH L8630 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031293 SUPPLIES METACARPOPHAL IMPLANT LVL 5 EACH L8630 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27004480 SUPPLIES MINOR CRANI PACK-LF EACH $836.00 272 $585.20 $418.00 $668.80 65% 80% 50% 50% 65% 65% 65% 27005180 SUPPLIES MINOR SET UP OFH PACK EACH $81.00 272 $56.70 $40.50 $64.80 65% 80% 50% 50% 65% 65% 65% 27014778 SUPPLIES NEEDLE LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27014844 SUPPLIES NEEDLE LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27015478 SUPPLIES NEEDLE LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27014919 SUPPLIES NEEDLE LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27014984 SUPPLIES NEEDLE LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27015056 SUPPLIES NEEDLE LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27015122 SUPPLIES NEEDLE LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27015197 SUPPLIES NEEDLE LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27015262 SUPPLIES NEEDLE LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27015338 SUPPLIES NEEDLE LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27015403 SUPPLIES NEEDLE LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27015544 SUPPLIES NEUROSTIM ACCESSORIES LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27015619 SUPPLIES NEUROSTIM ACCESSORIES LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27016245 SUPPLIES NEUROSTIM ACCESSORIES LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27015684 SUPPLIES NEUROSTIM ACCESSORIES LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27015759 SUPPLIES NEUROSTIM ACCESSORIES LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27015825 SUPPLIES NEUROSTIM ACCESSORIES LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27015890 SUPPLIES NEUROSTIM ACCESSORIES LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27015965 SUPPLIES NEUROSTIM ACCESSORIES LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27016039 SUPPLIES NEUROSTIM ACCESSORIES LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27016104 SUPPLIES NEUROSTIM ACCESSORIES LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27016179 SUPPLIES NEUROSTIM ACCESSORIES LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27030469 SUPPLIES NON-PNEUM WALK BOOT LVL 0 EACH L4386 $160.00 274 $112.00 $80.00 $128.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030527 SUPPLIES NON-PNEUM WALK BOOT LVL 1 EACH L4386 $160.00 274 $112.00 $80.00 $128.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030535 SUPPLIES NON-PNEUM WALK BOOT LVL 2 EACH L4386 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030592 SUPPLIES NON-PNEUM WALK BOOT LVL 3 EACH L4386 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030600 SUPPLIES NON-PNEUM WALK BOOT LVL 4 EACH L4386 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030667 SUPPLIES NON-PNEUM WALK BOOT LVL 5 EACH L4386 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030881 SUPPLIES OCULAR IMPLANT LVL 0 EACH L8610 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030949 SUPPLIES OCULAR IMPLANT LVL 1 EACH L8610 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030956 SUPPLIES OCULAR IMPLANT LVL 2 EACH L8610 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031012 SUPPLIES OCULAR IMPLANT LVL 3 EACH L8610 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031020 SUPPLIES OCULAR IMPLANT LVL 4 EACH L8610 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031087 SUPPLIES OCULAR IMPLANT LVL 5 EACH L8610 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27004555 SUPPLIES OPEN HEART CDS-LF QPLUS BLADE EACH "$2,162.00 " 272 "$1,513.40 " "$1,081.00 " "$1,729.60 " 65% 80% 50% 50% 65% 65% 65% 27031368 SUPPLIES OSSICULA IMPLANT LVL 0 EACH L8613 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031376 SUPPLIES OSSICULA IMPLANT LVL 1 EACH L8613 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031715 SUPPLIES OSSICULA IMPLANT LVL 10 EACH L8613 "$26,000.00 " 278 "$18,200.00 " "$13,000.00 " "$20,800.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031434 SUPPLIES OSSICULA IMPLANT LVL 2 EACH L8613 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031442 SUPPLIES OSSICULA IMPLANT LVL 3 EACH L8613 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031509 SUPPLIES OSSICULA IMPLANT LVL 4 EACH L8613 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031517 SUPPLIES OSSICULA IMPLANT LVL 5 EACH L8613 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031574 SUPPLIES OSSICULA IMPLANT LVL 6 EACH L8613 "$5,000.00 " 278 "$3,500.00 " "$2,500.00 " "$4,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031582 SUPPLIES OSSICULA IMPLANT LVL 7 EACH L8613 "$9,400.00 " 278 "$6,580.00 " "$4,700.00 " "$7,520.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031640 SUPPLIES OSSICULA IMPLANT LVL 8 EACH L8613 "$15,000.00 " 278 "$10,500.00 " "$7,500.00 " "$12,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031657 SUPPLIES OSSICULA IMPLANT LVL 9 EACH L8613 "$20,000.00 " 278 "$14,000.00 " "$10,000.00 " "$16,000.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27023241 SUPPLIES PERI STRIP LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27023316 SUPPLIES PERI STRIP LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27023944 SUPPLIES PERI STRIP LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27023381 SUPPLIES PERI STRIP LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27023456 SUPPLIES PERI STRIP LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27023522 SUPPLIES PERI STRIP LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27023597 SUPPLIES PERI STRIP LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27023662 SUPPLIES PERI STRIP LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27023738 SUPPLIES PERI STRIP LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27023803 SUPPLIES PERI STRIP LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27023878 SUPPLIES PERI STRIP LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27033117 SUPPLIES PLATE BN 190X140MM TI 9200647 EACH "$25,395.00 " 272 "$17,776.50 " "$12,697.50 " "$20,316.00 " 65% 80% 50% 50% 65% 65% 65% 27017086 SUPPLIES PROBE LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27017151 SUPPLIES PROBE LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27017789 SUPPLIES PROBE LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27017227 SUPPLIES PROBE LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27017292 SUPPLIES PROBE LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27017367 SUPPLIES PROBE LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27017433 SUPPLIES PROBE LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27017508 SUPPLIES PROBE LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27017573 SUPPLIES PROBE LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27017649 SUPPLIES PROBE LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27017714 SUPPLIES PROBE LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27017854 SUPPLIES REAMER LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27017920 SUPPLIES REAMER LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27018555 SUPPLIES REAMER LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27017995 SUPPLIES REAMER LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27018068 SUPPLIES REAMER LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27018134 SUPPLIES REAMER LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27018209 SUPPLIES REAMER LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27018274 SUPPLIES REAMER LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27018340 SUPPLIES REAMER LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27018415 SUPPLIES REAMER LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27018480 SUPPLIES REAMER LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27033042 SUPPLIES ROD XTRNFX 111MM 50497018 EACH "$24,549.00 " 272 "$17,184.30 " "$12,274.50 " "$19,639.20 " 65% 80% 50% 50% 65% 65% 65% 27003011 SUPPLIES ROTATABLE RETRIEVAL BASKET EACH $285.00 272 $199.50 $142.50 $228.00 65% 80% 50% 50% 65% 65% 65% 27002948 SUPPLIES ROTH NET - FOREIGN BODY EACH $267.00 272 $186.90 $133.50 $213.60 65% 80% 50% 50% 65% 65% 65% 27029206 SUPPLIES SHLDER FIG 8 ABDUCT LVL 0 EACH L3650 $75.00 274 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029263 SUPPLIES SHLDER FIG 8 ABDUCT LVL 1 EACH L3650 $150.00 274 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029271 SUPPLIES SHLDER FIG 8 ABDUCT LVL 2 EACH L3650 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029339 SUPPLIES SHLDER FIG 8 ABDUCT LVL 3 EACH L3650 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029347 SUPPLIES SHLDER FIG 8 ABDUCT LVL 4 EACH L3650 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029404 SUPPLIES SHLDER FIG 8 ABDUCT LVL 5 EACH L3650 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27018621 SUPPLIES SLEEVE LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27018696 SUPPLIES SLEEVE LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27019322 SUPPLIES SLEEVE LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27018761 SUPPLIES SLEEVE LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27018837 SUPPLIES SLEEVE LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27018902 SUPPLIES SLEEVE LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27018977 SUPPLIES SLEEVE LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27019041 SUPPLIES SLEEVE LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27019116 SUPPLIES SLEEVE LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27019181 SUPPLIES SLEEVE LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27019256 SUPPLIES SLEEVE LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27005396 SUPPLIES SNARE POLYPECTOMY MEDIUM EACH $93.00 272 $65.10 $46.50 $74.40 65% 80% 50% 50% 65% 65% 65% 27005321 SUPPLIES SNARE POLYPECTOMY SMALL EACH $93.00 272 $65.10 $46.50 $74.40 65% 80% 50% 50% 65% 65% 65% 27004621 SUPPLIES SPINE PACK-LF EACH $509.00 272 $356.30 $254.50 $407.20 65% 80% 50% 50% 65% 65% 65% 27002765 SUPPLIES SPLINT FOOT DROP PREFAB EACH L4398 $0.00 274 $0.00 $0.00 $0.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27026327 SUPPLIES SPLINT SUPPLIES MISC LVL 0 EACH Q4051 $75.00 270 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27026335 SUPPLIES SPLINT SUPPLIES MISC LVL 1 EACH Q4051 $150.00 270 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27026392 SUPPLIES SPLINT SUPPLIES MISC LVL 2 EACH Q4051 $300.00 270 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27026400 SUPPLIES SPLINT SUPPLIES MISC LVL 3 EACH Q4051 $600.00 270 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27026467 SUPPLIES SPLINT SUPPLIES MISC LVL 4 EACH Q4051 "$1,200.00 " 270 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27026475 SUPPLIES SPLINT SUPPLIES MISC LVL 5 EACH Q4051 "$2,400.00 " 270 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27003292 SUPPLIES SPT ENDOSCOPIC MARKER EACH $63.00 272 $44.10 $31.50 $50.40 65% 80% 50% 50% 65% 65% 65% 27033323 SUPPLIES STNT EPRSTH THOR AORTA 10CM 21 EACH "$25,608.00 " 272 "$17,925.60 " "$12,804.00 " "$20,486.40 " 65% 80% 50% 50% 65% 65% 65% 27033331 SUPPLIES STNT EPRSTH THOR AORTA 10CM 26 EACH "$26,249.00 " 272 "$18,374.30 " "$13,124.50 " "$20,999.20 " 65% 80% 50% 50% 65% 65% 65% 27033398 SUPPLIES STNT EPRSTH THOR AORTA 10CM 40 EACH "$26,249.00 " 272 "$18,374.30 " "$13,124.50 " "$20,999.20 " 65% 80% 50% 50% 65% 65% 65% 27033612 SUPPLIES STNT EPRSTH THOR AORTA 10CM 40 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27033406 SUPPLIES STNT EPRSTH THOR AORTA 15CM 31 EACH "$26,249.00 " 272 "$18,374.30 " "$13,124.50 " "$20,999.20 " 65% 80% 50% 50% 65% 65% 65% 27033547 SUPPLIES STNT EPRSTH THOR AORTA 15CM 31 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27033463 SUPPLIES STNT EPRSTH THOR AORTA 15CM 45 EACH "$26,249.00 " 272 "$18,374.30 " "$13,124.50 " "$20,999.20 " 65% 80% 50% 50% 65% 65% 65% 27033679 SUPPLIES STNT EPRSTH THOR AORTA 15CM 45 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27033471 SUPPLIES STNT EPRSTH THOR AORTA 20CM 34 EACH "$25,608.00 " 272 "$17,925.60 " "$12,804.00 " "$20,486.40 " 65% 80% 50% 50% 65% 65% 65% 27033604 SUPPLIES STNT EPRSTH THOR AORTA 20CM 34 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27033539 SUPPLIES STNT EPRSTH THOR AORTA 20CM 45 EACH "$25,608.00 " 272 "$17,925.60 " "$12,804.00 " "$20,486.40 " 65% 80% 50% 50% 65% 65% 65% 27033687 SUPPLIES STNT EPRSTH THOR AORTA 20CM 45 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27025493 SUPPLIES SURGICAL SUPPLY LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27025550 SUPPLIES SURGICAL SUPPLY LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27025840 SUPPLIES SURGICAL SUPPLY LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27025568 SUPPLIES SURGICAL SUPPLY LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27025626 SUPPLIES SURGICAL SUPPLY LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27025634 SUPPLIES SURGICAL SUPPLY LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27025691 SUPPLIES SURGICAL SUPPLY LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27025709 SUPPLIES SURGICAL SUPPLY LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27025766 SUPPLIES SURGICAL SUPPLY LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27025774 SUPPLIES SURGICAL SUPPLY LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27025832 SUPPLIES SURGICAL SUPPLY LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27809615 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27809623 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27809714 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27809631 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27809649 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27809656 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27809664 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27809672 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27809680 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27809698 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27809706 SUPPLIES SURGICAL SUPPLY/IMPLANT LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27030675 SUPPLIES SYN IMPLNT URINARY 1ML LVL 0 EACH L8606 $75.00 278 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030733 SUPPLIES SYN IMPLNT URINARY 1ML LVL 1 EACH L8606 $150.00 278 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030741 SUPPLIES SYN IMPLNT URINARY 2ML LVL 2 EACH L8606 $300.00 278 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030808 SUPPLIES SYN IMPLNT URINARY 3ML LVL 3 EACH L8606 $600.00 278 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030816 SUPPLIES SYN IMPLNT URINARY 4ML LVL 4 EACH L8606 "$1,200.00 " 278 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030873 SUPPLIES SYN IMPLNT URINARY 5ML LVL 5 EACH L8606 "$2,400.00 " 278 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27004696 SUPPLIES THORACIC PACK-LF EACH $258.00 272 $180.60 $129.00 $206.40 65% 80% 50% 50% 65% 65% 65% 27033125 SUPPLIES TISSUE SNTH MDPR CSTM 54440610 EACH "$23,478.00 " 272 "$16,434.60 " "$11,739.00 " "$18,782.40 " 65% 80% 50% 50% 65% 65% 65% 27019397 SUPPLIES TROCAR LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27019462 SUPPLIES TROCAR LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27020098 SUPPLIES TROCAR LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27019538 SUPPLIES TROCAR LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27019603 SUPPLIES TROCAR LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27019678 SUPPLIES TROCAR LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27019744 SUPPLIES TROCAR LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27019819 SUPPLIES TROCAR LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27019884 SUPPLIES TROCAR LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27019959 SUPPLIES TROCAR LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27020023 SUPPLIES TROCAR LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27020163 SUPPLIES TUBE LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27020239 SUPPLIES TUBE LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27020866 SUPPLIES TUBE LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27020304 SUPPLIES TUBE LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27020379 SUPPLIES TUBE LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27020445 SUPPLIES TUBE LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27020510 SUPPLIES TUBE LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27020585 SUPPLIES TUBE LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27020650 SUPPLIES TUBE LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27020726 SUPPLIES TUBE LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27020791 SUPPLIES TUBE LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27004761 SUPPLIES UNIVERSAL TRAUMA PACK-LF EACH $251.00 272 $175.70 $125.50 $200.80 65% 80% 50% 50% 65% 65% 65% 27029834 SUPPLIES UPP EXT FX ORTH HUMERAL LVL 0 EACH L3980 $354.00 274 $247.80 $177.00 $283.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029891 SUPPLIES UPP EXT FX ORTH HUMERAL LVL 1 EACH L3980 $354.00 274 $247.80 $177.00 $283.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029909 SUPPLIES UPP EXT FX ORTH HUMERAL LVL 2 EACH L3980 $354.00 274 $247.80 $177.00 $283.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029966 SUPPLIES UPP EXT FX ORTH HUMERAL LVL 3 EACH L3980 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029974 SUPPLIES UPP EXT FX ORTH HUMERAL LVL 4 EACH L3980 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030030 SUPPLIES UPP EXT FX ORTH HUMERAL LVL 5 EACH L3980 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030048 SUPPLIES UPPER EXT FX ORTH WRIST LVL 0 EACH L3984 $317.00 274 $221.90 $158.50 $253.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030105 SUPPLIES UPPER EXT FX ORTH WRIST LVL 1 EACH L3984 $317.00 274 $221.90 $158.50 $253.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030113 SUPPLIES UPPER EXT FX ORTH WRIST LVL 2 EACH L3984 $317.00 274 $221.90 $158.50 $253.60 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030170 SUPPLIES UPPER EXT FX ORTH WRIST LVL 3 EACH L3984 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030188 SUPPLIES UPPER EXT FX ORTH WRIST LVL 4 EACH L3984 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27030246 SUPPLIES UPPER EXT FX ORTH WRIST LVL 5 EACH L3984 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27004837 SUPPLIES UPPER EXTREMITY PACK-LF EACH $210.00 272 $147.00 $105.00 $168.00 65% 80% 50% 50% 65% 65% 65% 27020932 SUPPLIES URINARY IMP ACCESSORIES LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27021005 SUPPLIES URINARY IMP ACCESSORIES LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27021633 SUPPLIES URINARY IMP ACCESSORIES LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27021070 SUPPLIES URINARY IMP ACCESSORIES LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27021146 SUPPLIES URINARY IMP ACCESSORIES LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27021211 SUPPLIES URINARY IMP ACCESSORIES LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27021286 SUPPLIES URINARY IMP ACCESSORIES LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27021351 SUPPLIES URINARY IMP ACCESSORIES LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27021427 SUPPLIES URINARY IMP ACCESSORIES LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27021492 SUPPLIES URINARY IMP ACCESSORIES LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27021567 SUPPLIES URINARY IMP ACCESSORIES LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27004902 SUPPLIES VASCULAR PACK-LF EACH $372.00 272 $260.40 $186.00 $297.60 65% 80% 50% 50% 65% 65% 65% 27021708 SUPPLIES VEIN HARVESTING SYSTEM LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27021773 SUPPLIES VEIN HARVESTING SYSTEM LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27022409 SUPPLIES VEIN HARVESTING SYSTEM LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27021849 SUPPLIES VEIN HARVESTING SYSTEM LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27021914 SUPPLIES VEIN HARVESTING SYSTEM LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27021989 SUPPLIES VEIN HARVESTING SYSTEM LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27022052 SUPPLIES VEIN HARVESTING SYSTEM LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27022128 SUPPLIES VEIN HARVESTING SYSTEM LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27022193 SUPPLIES VEIN HARVESTING SYSTEM LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27022268 SUPPLIES VEIN HARVESTING SYSTEM LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27022334 SUPPLIES VEIN HARVESTING SYSTEM LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27031939 SUPPLIES WALKING BOOT PNEUMATIC LVL 0 EACH L4360 $260.00 274 $182.00 $130.00 $208.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27031996 SUPPLIES WALKING BOOT PNEUMATIC LVL 1 EACH L4360 $260.00 274 $182.00 $130.00 $208.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032002 SUPPLIES WALKING BOOT PNEUMATIC LVL 2 EACH L4360 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032069 SUPPLIES WALKING BOOT PNEUMATIC LVL 3 EACH L4360 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032077 SUPPLIES WALKING BOOT PNEUMATIC LVL 4 EACH L4360 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032135 SUPPLIES WALKING BOOT PNEUMATIC LVL 5 EACH L4360 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029628 SUPPLIES WHFO NONTOR JOINT PREFAB L0 EACH L3931 $901.00 274 $630.70 $450.50 $720.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029685 SUPPLIES WHFO NONTOR JOINT PREFAB L1 EACH L3931 $191.00 274 $133.70 $95.50 $152.80 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029693 SUPPLIES WHFO NONTOR JOINT PREFAB L2 EACH L3931 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029750 SUPPLIES WHFO NONTOR JOINT PREFAB L3 EACH L3931 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029768 SUPPLIES WHFO NONTOR JOINT PREFAB L4 EACH L3931 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029826 SUPPLIES WHFO NONTOR JOINT PREFAB L5 EACH L3931 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27022474 SUPPLIES WIRE LVL 0 EACH $75.00 272 $52.50 $37.50 $60.00 65% 80% 50% 50% 65% 65% 65% 27022540 SUPPLIES WIRE LVL 1 EACH $150.00 272 $105.00 $75.00 $120.00 65% 80% 50% 50% 65% 65% 65% 27023175 SUPPLIES WIRE LVL 10 EACH "$26,000.00 " 272 "$18,200.00 " "$13,000.00 " "$20,800.00 " 65% 80% 50% 50% 65% 65% 65% 27022615 SUPPLIES WIRE LVL 2 EACH $300.00 272 $210.00 $150.00 $240.00 65% 80% 50% 50% 65% 65% 65% 27022680 SUPPLIES WIRE LVL 3 EACH $600.00 272 $420.00 $300.00 $480.00 65% 80% 50% 50% 65% 65% 65% 27022755 SUPPLIES WIRE LVL 4 EACH "$1,200.00 " 272 $840.00 $600.00 $960.00 65% 80% 50% 50% 65% 65% 65% 27022821 SUPPLIES WIRE LVL 5 EACH "$2,400.00 " 272 "$1,680.00 " "$1,200.00 " "$1,920.00 " 65% 80% 50% 50% 65% 65% 65% 27022896 SUPPLIES WIRE LVL 6 EACH "$5,000.00 " 272 "$3,500.00 " "$2,500.00 " "$4,000.00 " 65% 80% 50% 50% 65% 65% 65% 27022961 SUPPLIES WIRE LVL 7 EACH "$9,400.00 " 272 "$6,580.00 " "$4,700.00 " "$7,520.00 " 65% 80% 50% 50% 65% 65% 65% 27023035 SUPPLIES WIRE LVL 8 EACH "$15,000.00 " 272 "$10,500.00 " "$7,500.00 " "$12,000.00 " 65% 80% 50% 50% 65% 65% 65% 27023100 SUPPLIES WIRE LVL 9 EACH "$20,000.00 " 272 "$14,000.00 " "$10,000.00 " "$16,000.00 " 65% 80% 50% 50% 65% 65% 65% 27029412 SUPPLIES WRIST COCK-UP NON-MOLDED L0 EACH L3908 $75.00 274 $52.50 $37.50 $60.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029479 SUPPLIES WRIST COCK-UP NON-MOLDED L1 EACH L3908 $150.00 274 $105.00 $75.00 $120.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029487 SUPPLIES WRIST COCK-UP NON-MOLDED L2 EACH L3908 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029545 SUPPLIES WRIST COCK-UP NON-MOLDED L3 EACH L3908 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029552 SUPPLIES WRIST COCK-UP NON-MOLDED L4 EACH L3908 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27029610 SUPPLIES WRIST COCK-UP NON-MOLDED L5 EACH L3908 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032143 SUPPLIES WRIST-HAND-FINGER ORTHOTC LV 0 EACH L3807 $229.00 274 $160.30 $114.50 $183.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032200 SUPPLIES WRIST-HAND-FINGER ORTHOTC LV 1 EACH L3807 $229.00 274 $160.30 $114.50 $183.20 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032218 SUPPLIES WRIST-HAND-FINGER ORTHOTC LV 2 EACH L3807 $300.00 274 $210.00 $150.00 $240.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032275 SUPPLIES WRIST-HAND-FINGER ORTHOTC LV 3 EACH L3807 $600.00 274 $420.00 $300.00 $480.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032283 SUPPLIES WRIST-HAND-FINGER ORTHOTC LV 4 EACH L3807 "$1,200.00 " 274 $840.00 $600.00 $960.00 Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 27032341 SUPPLIES WRIST-HAND-FINGER ORTHOTC LV 5 EACH L3807 "$2,400.00 " 274 "$1,680.00 " "$1,200.00 " "$1,920.00 " Non Payable Non Payable INVOICE COST + fees if > than $2500 Charges INVOICE COST > $2500 35% of Billed Charges if > than $3K Billed Cost + 15% if over $1k Billed Amount Cost + 15% if over $1k Billed Amount 36000107 SURGERY (FACILITY CHARGE) SURGERY BASIC LEVEL 1 - 1ST HOUR FIRST 60 MINUTES "$6,314.00 " 360 "$4,419.80 " "$3,157.00 " "$5,051.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 36000107 SURGERY (FACILITY CHARGE) SURGERY BASIC LEVEL 1 - EACH ADDL 30 MINUTES EACH ADDL 30 MINUTES "$2,842.00 " 360 "$1,989.40 " "$1,421.00 " "$2,273.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 36000248 SURGERY (FACILITY CHARGE) SURGERY COMPL LEVEL 3 - 1ST HOUR FIRST 60 MINUTES "$10,172.00 " 360 "$7,120.40 " "$5,086.00 " "$8,137.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 36000248 SURGERY (FACILITY CHARGE) SURGERY COMPL LEVEL 3 - EACH ADDL 30 MINUTES EACH ADDL 30 MINUTES "$4,577.00 " 360 "$3,203.90 " "$2,288.50 " "$3,661.60 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 36000172 SURGERY (FACILITY CHARGE) SURGERY INTER LEVEL 2 - 1ST HOUR FIRST 60 MINUTES "$8,551.00 " 360 "$5,985.70 " "$4,275.50 " "$6,840.80 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable 36000172 SURGERY (FACILITY CHARGE) SURGERY INTER LEVEL 2 - EACH ADDL 30 MINUTES EACH ADDL 30 MINUTES "$3,849.00 " 360 "$2,694.30 " "$1,924.50 " "$3,079.20 " 65% Covered Charges NTE $5339/case 80% Covered Charges NTE $1501/case Non Payable Non Payable Non Payable Non Payable Non Payable